Does my high cholesterol mean I need to take a statin?

My recent routine visit to the doctor’s office raised the question, again, “Does my high cholesterol mean I need to take a statin?”

** My first disclaimer is that my research relates to me. I will provide you with an incomplete list of my research links and background information. You may find other links more helpful and that’s great. **

Just a few weeks ago I was able to get in to see a Physician’s Assistant (PA) in my doctor’s office for a routine visit. I took the opportunity to do that rather than wait for the doctor. The PA did all of the normal exam items, including order a standard lipid test. My results:

Total cholesterol: 292 mg/DL

HDL: 98 mg/DL

LDL Calculated: 175 mg/DL

Triglycerides: 82 mg/DL

When the results came back, the PA asked how I felt about going on a statin. Based on my last journey through this decision-making process, I pushed back and asked for more information. After some discussion, we decided it was best to do further lipid testing where LDL is actually measured versus calculated. Additionally, she ordered a test to measure Lipoprotein (a), also called LPa, and finally she ordered a second CT Calcium Score test since it has been about seven years since my last test. This CT test directly measures the amount of calcified plaque in the heart.

I was completely on board with the next steps in testing because I want to be judicious about the decision to take – or not take – a statin.

Updated results after further testing:

LDL measured: 141 mg/DL

The direct measure of LDL puts me in another, lower, risk category than the calculated value:

NCEP ATP III guidelines: <100 mg/dL Desirable
100-129 mg/dL Above Desirable
130-159 mg/dL Borderline High
160-189 mg/dL High
190 mg/dL Very High

My LPa test value was “deemed undetectable” in the PA notes, which was great news. High levels of LPa are thought to increase the likelihood of developing heart disease, according to some experts.

While waiting for all the testing to occur and to receive results, I went about my normal investigation of these types of matters. I was curious if anything new surfaced since my last investigation.

I did find a handful of online heart disease risk calculators. I had not seen these the last time I investigated heart disease risk assessment tools. Each tool uses slightly different items to evaluate the risk of heart disease. I think a multivariable evaluation is important because risk of heart disease is seldom (if ever?) linked to a single variable. The risk of developing heart disease is often associated with some of the items on this incomplete list:

Family history of heart disease
Diabetes
Smoking history
Blood pressure
Weight
Abdominal obesity
Cholesterol profile
Age (yes, getting older is a risk factor)
Sex
Race
Stress
Exercise or lack thereof (And no, you do not need to be an endurance athlete to have a healthy level of exercise.)

Every calculator used slightly different risk input values to determine the overall risk of developing heart disease in the next 10 years or so. Below is a short list of some of the risk calculators I found:

American College of Cardiology (ACC) Risk Estimator

(If you are over the age of 59, the ACC calculator warns you it only estimates risk for ages 20-59.)

ACC/AHA Risk Calculator

Framingham General CVD Risk Profile

Reynolds Risk Score

My ASCVD (atherosclerotic cardiovascular disease) risk scores from each of the calculators above are 2.8%, 2.8% , 1.2%, and N/A. I was unable to use the last calculator because I do not have a current value for C-Reactive Protein (CRP). These percentage values are my 10-year estimated risk scores for developing cardiovascular disease. Obviously quite low.

It is important to know that my blood pressure at my most recent visit was 106/60 and has historically been in this range. I have no family history of heart disease, have never been a smoker, am not diabetic and I do not consider myself under a lot of stress at this time. Have I previously been under what I consider a great deal of stress? Yes.

I think a few things are important to point out. First, it is well known that people with what doctors consider “normal” cholesterol levels can have heart disease and suffer fatal heart attacks. My friend Scott Ellis and famous news man Tim Russert (who had an LDL of 78) are examples. The caution here is that if you have “normal” cholesterol levels, do not assume you have no risk of heart disease.

One study of 4,100 people found that, “At the start of the study, participants were 40–54 years old and had ideal health, which was defined as being a non-smoker and having optimal blood pressure, blood sugar, and cholesterol. After conducting thorough medical exams at the start of the study, researchers found that 50% of participants had significant plaque build-up in their arteries.”

Another important concept to consider is something called dependent variables. A single variable by itself is not as important as the consideration of several variables and how they relate to one another.

The first important summary point is:

Your personal risk of heart disease and the likelihood of a heart attack depends on several variables. Whether or not you should be prescribed a statin to prevent the further development of heart disease depends on the specific values of multiple variables.

My final test result came in today and it is the CT Calcium Score. The score was zero in 2016 and remains zero in 2022. Very good news indeed.

When evaluating risk/benefit ratios of taking a statin, know there are disagreements among experts. Some believe that above a certain value, LDL must be reduced (independent of the value of any other variable(s)) in order to reduce risk of heart disease. Taking a statin is the way reduce LDL, so the message will be, “Take the statin.”

Other experts believe it isn’t that clearcut and that taking statins to lower LDL without considering dependent variables is not a reasonable conclusion. One reason for the pause is because statins come with certain risks.

Another important summary point is:

No matter which choice I make, take a statin or not, that choice comes with risks. Which set of risks am I willing to take?

I have made my decision on whether or not to take a statin. When I started this column, I was intent on letting you know that decision at the end of the column. After writing the column, I’ve decided that my decision is right for me. Given exactly the same health markers that I have, you might make a different decision. And that’s okay.

Are you wondering where to begin?

If it has been awhile since you’ve had an exam, get your fanny to the doctor’s office and get an “annual” checkup along with the standard tests determined by your doctor.
Depending on the results of your individual tests, have a discussion with your doctor about what steps to take next.
1. Do you need further tests?
2. What is your list of dependent variables?
3. Would you benefit from a CT Calcium Scan?
Make informed decisions about your personal health care. Ask for second opinions if you’re not comfortable with the recommendation made by a single health-care provider.

More links in no particular order:

New Study Suggests Benefit-to-Harm Balance of Statins for Healthy Adults ‘Generally Favorable’

Statins Provide No Clinical Benefit When Coronary Calcium Is Zero, Study Shows

Side Effect Patterns in a Crossover Trial of Statin, Placebo, and No Treatment

What to know about a zero calcium score with high cholesterol

The mainstream hypothesis that LDL cholesterol drives atherosclerosis may have been falsified by non-invasive imaging of coronary artery plaque burden and progression

The Russert Impact: A Golden Opportunity to Promote Primary Coronary Prevention

The common "good" and "bad" cholesterol levels myth is not true

Link between high cholesterol and heart disease 'inconsistent', new study finds.