Consultant Interventional Cardiologist
Circle Bath Hospital
01761 422 222
Personalised Management of High Cholesterol
A balanced approach in the cholesterol ‘expert’ civil war.
There is currently a huge amount of confusion in the public space around high cholesterol and its effects on cardiovascular health. In fact, if we are honest, there is a ‘civil war’ between so-called cholesterol experts with exaggerated agendas from both in the media and online which is difficult for the public to decipher. Which perspective should we believe?
The historical and usually mainstream academic and medical community, backed by large-scale industry-sponsored clinical research trials, believe and argue that the link between high cholesterol and cardiovascular disease (including angina, heart attacks and strokes) is fundamental.
As a result, current UK guidelines place cholesterol as the biggest risk factor for heart attack. This means that the population-based risk calculators (Q risk) used by doctors are heavily weighted towards your cholesterol measurements. If your 10-year risk of a cardiovascular event is over 10% (which it is for many simply as a statistical consequence of aging) then statin therapy is recommended as ‘primary prevention’, i.e. to prevent a future heart attack or stroke.
With 60% of adults over the threshold that would be defined as normal cholesterol in these guidelines, the majority require statin treatment. This camp are pro-statin and some have suggested that the benefits are so significant (and downsides / side effects so minor) that it should be supplemented in tap water.
The opposing camp come from a variety of backgrounds and include doctors, researchers, investigative journalists and alternative therapists. This group argue passionately that cholesterol is a fundamental physiological requirement for a well-functioning mind and body and that there is no or very little link between ‘high cholesterol’ parse and cardiovascular health problems or benefit from statins.
They suggest that the evidence has been manipulated by industry and conflict, highlighting the fact that Atorvastatin is the biggest mega-blockbuster drug of all time in terms of revenue generated for big pharma. Within this group there will be patient representatives who are convinced of long-term health problems affecting the brain, nervous system or muscles as a consequence of previous statin use.
The dietary perspectives further confuse the debate. The historical dogma that is still ingrained in most medical information, patient literature and advice is to go ‘low-fat’, eat high-fibre breakfast cereals and switch to margarine and Benecol to lower cholesterol. Despite this, you will be told that you can only expect to lower your cholesterol by around 10%.
The other camp tell you to eat fat (including from saturated animal sources) freely and are much more interested in sugar, refined carbohydrates and the consequences of insulin resistance which leads to type 2 diabetes and weight gain (usually around the belly).
There is a group of us (including me) who now listen objectively to both camps, and as with all things the truth is somewhere in the middle. The key is to not look at this from a general population perspective, but to use modern diagnostics to personalise the best treatment for the individual.
One of the things that attracts a lot of interest is my work around high cholesterol and statins. There is a lot of controversy currently around cholesterol, both within the general medical community and outside it. While the accepted wisdom is to take a statin to lower cholesterol, there are more people now suggesting that this approach is not correct, that the data has been misinterpreted and that we are actually overprescribing statins in this group.
While this ‘one-size-fits-all’ approach to the problem may at first glance appear to make treatment simpler, it doesn’t necessarily make it better. The reality is that the vast majority of people with isolated high cholesterol are being given population-based advice (i.e. to take a statin). They are not being given individual advice, which I believe misses a significant aspect of effective treatment.
Many people who come to see me with high cholesterol tell me that they would prefer not to have to take a statin, while others have experienced problems from medication. These people would then ordinarily find themselves caught in what is a bit of a vicious cycle, being told by a doctor that they need to take a statin, a medicine they do not want to take (or cannot tolerate), otherwise they risk having a heart attack.
As a doctor, I am passionate about the value of individual treatment pathways. What is the best treatment for one person may not necessarily be the best one for another. At Circle, we have the ability to ‘fine-tune’ management of high cholesterol for each individual, using medication, diet and lifestyle, and we see some quite remarkable results.
For this group of people, we use advanced non-invasive imaging techniques (including CT coronary calcium scoring and angiography) to help determine their individual risks and the best options for them to safely, effectively and reliably lower their cholesterol (or indeed not to worry about their cholesterol).
The vast majority of people that I see will typically have very high cholesterol, but no other cardiovascular risk factors. In the vast majority of cases, we can confidently tell them that they don’t need a statin, nor do they need to worry about their cholesterol profile. This is often a huge relief to people, as their cholesterol would otherwise be hanging over them in the future, causing anxiety every time they see their doctor. Rather than telling them they need to take a statin, we are able to give them closure on the subject.
Equally, there are people we can provide with robust data to suggest that they would, at a personalised level, benefit from pharmacological treatments and provide closure that they are doing the right thing on the balance of benefit and risk. This then becomes an informed, shared decision.
There is a third group (and we are very passionate about these patients) who do need to make a change but do not need to commit to tablet treatments. These patients can significantly improve their cholesterol profile (and associated risk factors) through prescribed and targeted dietary and lifestyle treatments.
(There is an urban myth in the medical community that you can only lower your cholesterol by 10% through dietary change. This is absolutely wrong. In an unselective population, you can expect to reduce it by at least 20%, and if you select the right patients, you can reduce it a lot further. Frankly, a lot of the information that’s out there at the moment about low-fat diets and avoiding saturated fat is historical. We provide people with a personal dietary approach based on current up-to-date evidence and thinking.)
This personal, tailored approach to the management of high cholesterol is transformative for so many of the people I see. We are able to give them a robust answer about whether or not they need to take a statin, or whether dietary and lifestyle changes will be sufficient.
It should be said of course that in some cases, the evidence and test data shows that somebody will benefit from taking a statin. In these cases, I have no hesitation in advising them of this. Again, it all comes down to a tailored approach. One size does not fit all for so many medical treatments, and this is certainly the case for the management of high cholesterol.
To learn more about how we can help manage your high cholesterol, please contact my PA, ‘Tash’ (Natasha Jones), on 01761 422287. Tash will be able to answer your questions and book an appointment for you at a time that is convenient to you.
I had an irregular heartbeat which led to what is called a ‘minor’ heart attack. An angiogram showed that I had significant ‘furring’ (a build-up of fatty deposits) in the arteries. This was causing a thickening of my arteries, increasing my risk of coronary heart disease and other cardiovascular problems. My cholesterol was high (there was a family history of this).
The advice I received from the hospital was that the only option I had was to take a statin to lower my cholesterol, so I was prescribed a statin and a beta blocker. I have never been one to take medicine unless absolutely essential (I don’t even like taking paracetamol), and so I was quite frustrated to have this medication described as my only option.
Through speaking with a friend who had experienced a heart attack, I came to meet Ali. Ali’s approach was different to what I had experienced in hospital, but it very much fitted with my own beliefs and what I was hoping for going forward. Talking with Ali, he opened my eyes to other options for managing high cholesterol, like changes in my diet. Nothing Ali told me was revolutionary or surprising; his approach advises us to do the things we all know we should be doing, but usually aren’t (eating healthily, exercising regularly etc.).
Ali changed my thinking. He told me from very early on that if I wasn’t going to do anything with the information we talked about, I would be better off taking a statin. With my dislike of medication, that was all the motivation I needed!
I went through the CardioFitr programme, which I found helpful. It was a very safe environment, one that gave me the confidence to push myself far more than I would have if I had gone to a gym by myself. This gave me a big mental boost.
Ali explained everything to me in depth, and I found his approach was always very balanced. He gave me all the information I needed to make my own decisions and choices. I found that my new-found awareness led to changes occurring naturally.
Since meeting Ali, I feel healthier and I don’t have the heart problems I had before. My cholesterol levels have come down and subsequent scans have shown that the build-up of fatty deposits in my arteries has gone. This is in line with how I feel in myself and is proof that Ali’s approach works.
I am now at the stage of seeing Ali for an annual check, but it is also reassuring to know that I can always pick up the phone and speak with him if I have any queries.
I had a cardiac incident a few years ago, and was admitted to hospital through A&E. I already knew that I had high cholesterol. I also knew that I had quite severe reactions to statins (this was sadly proven once again when I was prescribed three different statins to try to manage my cholesterol…).
I was fortunate to meet Ali fairly early on. We had a very good conversation about my diet, where he told me that if I didn’t make any changes, I would definitely need to take statins, regardless of side effects.
I really didn’t want to take statins. Although what Ali said made sense, I didn’t really want to agree with him, so I gave myself a month to try to prove him wrong! With this ‘I’ll-show-him’ mentality, I proceeded to behave myself and to do exactly what he said.
A month later, there was a marked improvement in my cholesterol level. I had also started losing some excess weight. At the end of the second month, I was feeling much better in myself and sleeping well.
Although I set out to prove Ali wrong, I am glad to say that I didn’t succeed!
Ali’s approach is collaborative. Once a month, I saw my GP to have my cholesterol checked. These results were then sent to Ali for his review. Over just a few months, blood tests showed that my cholesterol had decreased significantly.
I had an implantable loop recorder put in by Ali. This tiny device recorded the electrical signals and my heart rhythm continually, with the data it captured uploaded wirelessly so that Ali could review it. If there was any unusual heart activity, the system would pick it up and notify Ali and his team.
I found the dietary advice Ali gave me was helpful and the food was very nice. It took a while to properly adjust to things, but I don’t feel like I’m missing out on anything. I travel a lot for work, and find hotels are happy to make adjustments to menus for me.
Ali gave me easy guidelines to live by. As a result of his advice, I do not need to take a statin and I have lost weight. I followed the dietary and lifestyle advice Ali gave me and am very happy with the results.
- Cardiac arrhythmia treatment
- Cardiac pacing
- Cardiology diagnostics
- Cardiovascular screening
- Non-invasive cardiology treatments
- Coronary angioplasty (PCI)
- Heart failure treatment
- Hypertension treatment
- Transthoracic echocardiography
- Microbubble testing (myocardial contrast echocardiography)