My wife just got the results from her lipid panel. Readings compared to 2019 included total cholesterol 215 to 290, LDL 112 to 192 and non-HDL C from 130 to 211. Nothing else unusual in the lipid panel or other bloodwork. She’s 67 and otherwise healthy, good weight, exercise, etc.
She will talk to her doctor, but meanwhile, are these increases plausible? What might cause them? Is this a case for re-testing (perhaps fasted) or is it a case for immediate aggressive statins or ?
Certainly a major change from a few years prior. Several things can impact this:
-Dietary changes (e.g., increases in animal-derived saturated fat intake, particularly butter)
-Insulin resistance (e.g., due to changes in bodyweight/body fat, or medications such as corticosteroids, antipsychotics, and others)
-Physiologic changes due to menopause (although this would be a bit late, given the age and time interval you describe, and would not typically have this magnitude of effect)
-Other medical issues (e.g., hypothyroidism, or rarer causes such as nephrotic syndrome and rare liver disorders)
It would be reasonable to re-check fasted as there is some impact from that (although not to this magnitude), as well as normal lab variability (so could also consider using a different lab). If she is otherwise healthy with no cardiovascular history, there is no “urgency” to initiating aggressive treatment immediately. If a repeat lab confirms this finding, rules out hypothyroidism (via TSH measurement), and assuming we don’t have reason to blame any of the other causes listed above, then initiating treatment would probably be wise (although I can’t get into specifics without knowing more about her).
So far as I know, there have not been any of the changes listed. Her doctor sent a message that LDL was quite high and recommended less red meat, dietary fat and carbs, doing cardio (30-40 minutes 3-4x/week). I’m not clear on why less carbs (perhaps insulin resistance?), and she’s already walking over an hour most days and is doing resistance training 3x a week. She is otherwise healthy with no CV history. A few years ago her a1c levels were high, so she lost a lot of weight and decreased carbs, after which a1c and fasted glucose tolerance came back normal. The 2019 test was with a different doctor at a different lab. TSH was normal in 2019 and prior years.
Her doctor scheduled a fasted lipid panel at another lab, but not TSH. Would it be worth asking the doctor about testing TSH? Is there anything else you’d suggest she ask her doctor?
No urgency is good to hear. Thank you.
If she has had abnormal A1c/glucose levels in the past, I’d recheck those (if not done already), and a TSH, yes.
Her retest (which ended up being at the same lab) showed slightly improved levels, but still high. Her doctor said she “may benefit” from atorvastatin 10mg daily. Running her numbers through the statndard ASCVD risk calculator showed her 10 year risk at about 6% (changing female to male increases that to 12%). She had sent the doctor her 2019 lipid panel, which did not lead to anything other than the doctor noting the large increase.
Going through her diet, saturated fat is above 10% of calories and fiber averages about 20g/day. The ASCVD calculator finds her risk to be borderline (~6%) and only slightly lower with statins (5.5%). Changing her diet and retesting might be a better strategy than starting statins now. Weight is good and BP is good (110/73). She exceeds exercise guidelines.
Would that make sense for a general person in this situation?
That sounds reasonable to me based on 10-year risk assessments, although as we have discussed elsewhere her lifetime risk will be higher compared with a more limited 10-year time horizon.
Wife decided to see a cardiologist. He attributed the increase in her numbers to age. He noted that if you use her numbers in the ACC ASCVD risk calculator but add a few years to her age, the risk goes up sharply. He recommended a book called Prevent And Reverse Heart Disease: The Revolutionary, Scientifically Proven, Nutrition-Based Cure by Caldwell Esselstyn. He also scheduled her for more tests: CAC, echocardiogram and stress test.
Doing the CAC test for a statin decision seems pretty normal. I’d guess the other tests help with a risk assessment - would the idea be the outcomes would also help assess how to proceed with statins?
The cardiologist said the echo and stress test would “establish a baseline”.
I would not be pursuing an echocardiogram or stress test in this situation, based on the information you’ve provided so far.
That’s what I’m reading. The vast majority of articles I’ve seen are to the effect that these tests are only useful if you’re symptomatic or at high risk. She’s not symptomatic and her lipid panel does not appear to demonstrate high risk. One exception is Screening echocardiograms in a senior focused value based primary care improves systolic heart failure detection and clinical management - PMC (nih.gov) but as I read it the only management effect is to lead to treatment for high BP (not an issue here) and cholesterol (obviously there are other ways to decide about this).
I’m also not happy about a book which recommends a vegan diet with no oils, nuts or avocados. Compare. https://www.acc.org/latest-in-cardiology/articles/2020/08/24/09/38/comparison-of-dietary-and-exercise-recommendations or your writings.
Age alone does not appear to be a reasonable explanation for a rapid increase in cholesterol.
However, a CAC seems reasonable.
In case it’s of any interest, she got a CAC score of zero. According to the MESA risk calculator “The estimated 10-year risk of a CHD event for a person with this risk factor profile including coronary calcium is 1.4%. The estimated 10-year risk of a CHD event for a person with this risk factor profile if we did not factor in their coronary calcium score would be 2.9%.” Zero puts her in the 10th percentile - 90% of females around her age have a higher score. Hard to see how anyone could get much lower risk, especially at her age. Accordingly, she plans to stop doing anything with that cardiologist, possibly tinker with her diet (more plants and fiber, less saturated fats) and not start statins, at least for the moment.
Would you do another lipid panel sooner than one year?
Agree with this plan.
I don’t see a need for that.
