Are You in Your Doctor’s Blind Spot?

Louis B. Malinow, MD
By Louis B. Malinow, MD
February 15, 2018
You May Need More than Just a Cholesterol Test to Determine Your Risk for Heart Disease

Every so often I have a new patient and need to scour their medical record to prepare for their appointment. In all the years I’ve been practicing, I often notice that records are missing appropriate testing to assess risk of a heart attack. This also includes records from cardiology offices.

Yes, I see routine cholesterol profiles all the time. You know, the screening that includes total cholesterol, LDL (“bad” cholesterol), HDL ("good" cholesterol) and triglycerides. But if this is all the heart disease profiling you’ve ever had, your doctor is betting YOUR LIFE on inadequate data and their best GUESS as to what's really going on inside of you.

Here’s the truth: Cholesterol is critical for life. It’s so critical that every single cell in the body – except for adrenal gland and gonad cells — can make its own cholesterol. Adrenal glands and gonads still rely on cholesterol but as a delivery service for the hormones they produce.

It’s common to confuse the cholesterol in your body with the cholesterol you eat but don’t – they have very little connection with one another. Only 15 percent of the cholesterol in the bloodstream comes from food. The remaining 85 percent is from bile produced by the liver.

Many people think cholesterol floats freely around the bloodstream — it can’t; it's not water soluble. Instead, it gets packaged into "particles" called lipoproteins that act drop off cholesterol throughout the body. 

The best way to describe how lipoproteins work is to imagine them as delivery vans. And each “van” has a logo on its side to help your body recognize which type of cholesterol it’s carrying. The “logo” for LDL particles is ApoB, a protein that wraps around the LDL particle. And for HDL particles, the “logo” is ApoA. But regardless if the lipoprotein is labeled ApoB or ApoA, it’s carrying some cholesterol and triglyceride.  

While I’m explaining the truth about cholesterol, I might as well debunk some popular myths.

MYTH 1: A total cholesterol higher than 200 is a risk for cardiovascular disease.

TRUTH: The 200 mg/dL cutoff for total cholesterol is ancient history. Think about it — if you’re HDLs (good cholesterol) are very high, you’ll have a higher total cholesterol. Lowering your HDLs will lower your total cholesterol. Would that be good for your arteries? Possibly not. HDLs might protect your arteries. 

MYTH 2: HDLs are good cholesterol and having a high number is protection from cardiac events.

TRUTH: A higher number of HDLs might, but not necessarily, protect you. Results from several failed drug trials suggested that it’s not how many HDLs you have that’s important, it’s how effective the HDL is at protecting your arteries. 

About 20 percent of cardiac events occur in people with HDL levels higher than 80. To give you some perspective, HDLs typically range between 40 and 60 mg/dL. Clearly, we need to stop referring to HDL as the “good” cholesterol. We’re expecting tests that determine how well HDL is functioning to be available soon.

MYTH 3: If your triglycerides are below 150, you don’t have to worry about them.

TRUTH: High triglycerides are probably the single biggest cardiovascular risk factor. So even though lab work classifies up to 150 as normal on lab work, I believe anything higher than 90 is too high and a risk for cardiovascular disease. Most people don’t realize it but there’s a connection between triglycerides and LDL particle number.

Here’s what you need to remember. LDLs, HDLs and triglycerides aren’t that important. It’s number of LDL particles that matter. Two patients can have an LDL of 130. Patient A has larger particles than patient B but patient B has more particles than patient A. Patient B, with more particles, is has a higher risk of cardiovascular disease because they’re manufacturing more LDLs. 

Particles can penetrate arteries and bond to arterial walls, inflaming them and eventually causing a blockage. And the amount of cholesterol that accumulates in the artery wall is proportionate to the particle number.

A lot of information is available on particle size — large and fluffy vs. small and dense. Ignore it. It’s irrelevant. The real danger is in the particle number, not size. A greater number of particles means a greater chance of particles accumulating in an artery. 

Triglycerides are a blood fat that stores unused calories. A diet high in sugar and processed grains causes them to rise. But they also help predict your number of LDL particles. And a triglycerides value of 90 or above usually coincides with a higher particle number. 

Fortunately, you can lower triglycerides rather quickly – within a couple of weeks — by adopting a low-carb diet. Results from a trial conducted several years ago found the Atkins Diet lowered particle numbers better than three other diets. Of course, make sure you discuss dietary changes with your doctor.

Next time you’re at your doctor’s office, advocate for yourself. Request an NMR lipoprofile or ApoB and ApoA testing at the very least. And educate your loved ones to do the same.

Without results from these types of tests, your doctor is betting your life on their best guess as to how many particles you have. If your doctor isn’t using this methodology -- typically because of unfamiliarity -- have them contact my office. I’m happy to discuss it with them and share articles I’ve written and show graphs that demonstrate particle size and underlying risk.

And I’m happy to report no blind spots in my practice.

Consult your primary care physician about arterial tests. And if you liked this blog post, you can follow Dr. Malinow on his Facebook page – Are you interested in an MDVIP-affiliated physician? Find one near you and begin your partnership in health »

This blog reflects the medical opinion of Dr. Lou Malinow, an MDVIP-affiliated internist, board-certified hypertension specialist and Diplomate of the American Board of Lipidology, and not necessarily the opinion of all physicians in the MDVIP national network.

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About the Author
Louis Malinow, MD Author

Louis B. Malinow, MD is an MDVIP-affiliated physician that's been practicing in Baltimore for more than 20 years. He's board certified in Internal Medicine, a certified Hypertension Specialist and a Diplomate of the American Board of Clinical Lipidology. Dr. Malinow graduated from the University of Maryland School of Medicine and completed his residency at Stanford University Hospital in Stanford, CA. Dr. Malinow is one of the only physicians in Maryland that specializes in both high blood pressure and high cholesterol management. He is also a member of the prestigious Alpha Omega Alpha medical honor society and is recognized by Best Doctors and Top Doctor by U.S. News & World Report and Baltimore Magazine. Dr. Malinow has appeared on numerous news programs advocating for preventive care and wellness.

View All Posts By Louis B Malinow, M.D.
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