Cholesterol treatment has drastically changed in the last 10 years. The biggest change came in 2013 with the ASCVD (atherosclerotic cardiovascular disease) risk score, developed by the American College of Cardiology. This was right after I graduated from medical school, which is awesome, because I had just spent 6 years learning the old way of treating cholesterol.

What Do Your Numbers Mean?

Your cholesterol number actually comes from a composite of 3 different levels. These are HDL (good cholesterol), LDL (bad cholesterol), and triglycerides (dietary fat). You get the total cholesterol by adding your HDL and LDL and 20% of your triglycerides. Generally the cut off for “high cholesterol” is over 200. But, having a total cholesterol over 200 is not always a bad thing. Actually, the ratio of these three components is much more important.

HDL is called “good cholesterol” because the more you have, the better for your heart. LDL is called “bad cholesterol” because it is the component that deposits in arteries that can cause plaques and heart attacks and strokes. So lets take a look at these two cholesterol profiles and compare:

Triglycerides-100, HDL-70, LDL-120, total cholesterol = 210

Triglycerides-100, HDL-30, LDL-140= total cholesterol = 190

The first profile has a high HDL and a moderate LDL and a high total cholesterol. The second profile has a low HDL and a high LDL, but the total cholesterol level is normal. The second profile is much worse than the first profile, even though the first profile has a “high” total cholesterol.

Why Is Cholesterol Important?

Prior to 2013, we would try to lower a patient’s cholesterol numbers using a variety of medications if the level was high. So even a young healthy woman with the first cholesterol profile above may be put on medication. We discovered that treating numbers is not the right way to do it. Why do we want low cholesterol in the first place? To decrease our risk of heart attack and stroke. A young healthy woman has a very low risk of heart attack and stroke to begin with. Using a medication to lower her cholesterol really wont help her that much.

On the other hand, lets say you have a 65 year-old man with high blood pressure and diabetes, but he has the second cholesterol profile above, with a “normal” total cholesterol number. Even with a normal number, his risk of heart attack and stroke is very high and we should use whatever medicaitons we can to decrease his risk of having one of those events.

ASCVD Risk Score

How do you determine someone’s risk of heart attack and stroke: the ASCVD risk score. The American College of Cardiology created this calculator to determine someone’s risk of ASCVD (heart attack and stroke) in the next 10 years. The calculator factors in your age, gender, race, total cholesterol, HDL, systolic blood pressure, use of blood pressure medication, whether or not you have diabetes, and whether or not you are a smoker. All of these factors are used to determine a percent chance of ASCVD in the next 10 years. A risk score <5% is considered low and medication should really not be used. A risk score of 5-7.5% may benefit from medication, and a risk >7.5% really should be on medication.

What Can We Do About It?

The medications we use to decrease your ASCVD risk are called statins. Some of their generic names are atorvastatin, rosuvastatin, simvastatin etc. Taking one of these medications once daily can decrease your risk of ASCVD by a relative 30-50%. For example, if your ASCVD without medication is 20%, we can get that down to a risk of 10-14% in the next 10 years. That may not seem like a lot, but multiply that by the population of the whole country, and you have potentially saved people from thousands of heart attacks.

Primary v Secondary Prevention

The ASCVD risk score is only used to determine if you should take a statin medication for primary prevention of ASCVD. You may recall in my article “So Wait, Should I Take An Aspirin Or Not?”, primary prevention is preventing an event from ever happening. Secondary prevention is preventing the event from happening again. If you have already had a heart attack or stroke, then the ASCVD risk score does not apply to you. Since you have already had ASCVD, you will need to focus on secondary prevention, which in most cases, is a combination of both aspirin and statins.

Changing guidelines can be confusing for both patients and doctors. People get used to hearing one thing, and then question when things are done another way. It is always good to question why a change is occuring when it is presented to you. As Wise Patients, I want you to be up to date on all the newest medical trends.

If you want to learn more about primary prevention of cardiovascular disease, check out my previous article “So Wait, Should I Take An Aspirin Or Not?” If you are interested in reading about the newest ways we are delivering care during the pandemic, read my recent article “Virtual Doctoring“

Access the ASCVD risk calculator here to estimate your own risk now!

Curious about heart health? You may be interested in my previous article on Cardiac Stress Testing.