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LDL How Low To Go?

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  • LDL How Low To Go?

    Hi All,
    Recent new cardiologist wants my LDL-c below 50. I had full workup with particle size LDL-p and everything with LDL-c at 60 but this guy who is
    one of the best Cardiologists and lipoprotein specialists in my areas still is adamant about my LDL being less than 50.
    I have a good bit of plaque on a coronary artery and moderately elevated LPa (taking niacin for).
    Dr. added zetia to try to get LDL-c lower here..
    Any thoughts on why this Dr. wants my LDL even lower than it already is? Of course I worry about cognitive function with LDL-c soo low although when I bring this up Dr. cites studies and
    says it is not a concern even with people that have LDL-c's in the 20's and 30's? .
    Is a really low LDL-c suppose to make it impossible to obtain any plaque or something?

    Thank You All Very Much in Advance!

  • #2
    If a patient is deemed to have a high risk for cardiovascular disease, then yeah a lot of cardiologists would prefer that the patients have LDL-C no higher than 50 mg/dL. To my understanding the thinking is that the lower level of LDL-C will result in less plaque disposition in the future. Is there some risk in having an LDL-C in the 20-30 mg/dL range? There are a relatively few people who genetically have that low LDL-C level naturally. They don't have known cognitive issues and don't experience cardiovascular disease throughout their lifetimes. Does that translate into the broader population? Well, yes to a degree. I suppose that it depends upon the risk factor and whether a person has APOE E4 alleles. If you can get your LDL-C down to 50 mg/dL and your LDL-P to something like 700 nmol/L or lower, then you are probably doing ok enough. There are other markers to look at like TG/HDL-C, but you probably are well aware of that ratio relative to insulin resistance and how higher triglycerides will lower HDL-C levels. If you have APOE E4 alleles, then I personally would be cautious about going down to 20 mg/dL. Since you are a frequent contributor to the Forum, I imagine that you have gained a lot of knowledge through the videos and other material on cardiovascular inflammation. Hopefully your cardiologist also tracks your cardiovascular inflammation markers as those also make a big difference in evaluating risk.
    Last edited by Tom; 03-05-2020, 11:05 PM.

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    • #3
      Tom,
      Thank you sooo very much for the feedback.
      Dr. Brewer is very lucky to have you!
      i am APOE 3/3 so I don’t have any 4 alleles.
      I know I need LDL low but just sure sure if < 50 necessary.
      Dr. Esselstyn says below 70 is his target.
      i need to research a bit more and think.

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      • #4
        For what it's worth, I keep my LDL-C between 15 and 25 mg/dL with rosuvastatin and ezetimibe. HDL-C is around 50 mg/dL. If you're on atorvastatin now, I'd suggest switching to rosuvastatin.

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        • #5
          Kinpatu;
          thank you for your feedback.
          im on both Crestor 5 mg and zetia QOD.
          thats a low LDL-C U have.
          Whats your reason for keeping so low I’m curious?
          Also do u notice any cognitive differences, etc. from when
          yiur LDL-c was higher?
          Thank You.

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          • #6
            My LDL-C was around 100mg/dL for most of my adult life and increased to around 130mg/dL in my 40s. Not that high. I had severe cardiovascular disease detected by coronary artery calcium CT scan at age 46. My father died of sudden MI at age 48 with similar LDL-C levels. Lp(a) wasn't measured in his timeframe. I've measured mine, and it's slightly elevated but not excessively so. All I can hypothesize is that we have a genetic predisposition to poor endothelial function, but that's ultimately unknowable. Anyway the progression of my disease was such that throwing the kitchen sink at the problem is warranted in my opinion. I don't know that I'll stay at this level indefinitely; I may let it come back up to 30~40 mg/dL of non-HDL-C in the future. For now though, I seem to be tolerating the lipid lowering therapy well. My liver enzymes hover around the ULN. Atorvastatin gives me a backache, but I haven't experienced any noticeable myopathy on rosuvastatin. No cognitive differences.

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            • #7
              I don't know as much as you folks, just devouring information. I was concerned about the potential cognitive issues with statins for my husband, and since the brain needs cholesterol it didn't seem like a good thing for statins to cross the blood-brain barrier so I looked into whether there are statins that don't cross the BBB. Apparently rosuvastatin is one of them, so given it is so highly regarded by Dr. Brewer for inflammation, this seems like a win.

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              • #8
                Kinpatu, Rginis, my LDL was 29 the last time measured. I’ve experienced no mental decline from having a low level. And although statins caused me serious muscle pain to the point that I stopped taking them and got on Repatha, Pitavastatin, Zetia, and Niacin. All four to deal with my Familial Hypercholesterolemia TC 400-600 in my mid 40s now TC 109, Lp(a) over 1100 three years ago, and last year 450 now down to 373 with Niacin. My CAC is over 7,000. Got a cathlab, with LCA,99%, RCA, 100% Main Aortica, 75%. All with no symptoms. Then had a value job with a a 3Way side of Cabbage 2 years ago, but somehow never had heart attack or stroke. Still here at 75!

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                • Ford Brewer
                  Ford Brewer commented
                  Editing a comment
                  Knock 'em out, Joe!

              • #9
                I've been wondering about the impact of ethanol on my lipid profile. I've been LCHF for about two years and dropped about 45#s, (BMI 25.1) but my triglycerides, small LDL particles, insulin levels and OGTT are problematic (though my A1C has dropped to 5.3). I live in the wine country of Washington and belong to the wine clubs of a number of wineries in my area. Consequently I have a couple of glasses of wine nearly every night. I am in Dr. Brewer's program for preventive care and this is a topic he hasn't been raised in our interactions. I just finished the following article: J Hepatol. 2019 February ; 70(2): 237–248. doi:10.1016/j.jhep.2018.10.037 . The impact of ethanol on liver lipid genesis and regulation is vastly more pervasive and complex than I had realized. Conclusion: I don't plan to become a teetotaller, but I have begun to significantly reduce my ethanol intake and am taking mutii-day ethanol breaks. I'm thinking that a month of no alcohol, followed subsequently by consistent moderation might be a reasonable approach. I'd really appreciate the insight of others.
                Last edited by Kayak Greg; 08-05-2020, 02:16 PM.

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                • #10
                  I'm curious to see the reactions to this review of statin outcome. No new information, but it does review clinical trial outcomes.
                  Attached Files

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                  • #11
                    The alcohol/lipids connection has been hotly debated. The basic recommendation tends to boil down to 2/day or less for men, and half that for women. Yes, it is supposed to help with HDL. But as you know, it is not that simple. So, we focus on the top priorities ( I have a few, and I ask the patient/client to have a few) in our time together. Please bring this up in our next meeting. I'd love to hear more deeply your questions/concerns.

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                    • #12
                      Are there studies that show LDL below 60 stops or reverses heart disease? I'm talking in general, not people with Familial hypercholesterolemia.

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