1) Do I have artery disease?
At the Kahn Center a detailed history, physical, and review of any prior imaging studies like CT scans, ultrasounds, and heart testing is performed. Often a carotid IM thickness (CIMT) ultrasound is performed as it involves no X-rays, is painless, accurately identifies the health of important arteries, and can be repeated yearly to see if arteries are getting healthier. The CIMT is much more valuable than a standard carotid ultrasound. Other patients will also get a heart calcium CT scan at the hospital to identify silent heart artery aging. If there is artery damage the cholesterol needs to be kept low. If the arteries are free of plaque (like Dr. Kahn’s personal results), the cholesterol may not need any therapy.
2) Do I have a high cholesterol particle number?
About 20 years ago a more advanced lab panel was introduced that was shown to be more accurate than the standard one measuring only the total, LDL, and HDL cholesterol and triglycerides. This advanced panel measures the number of LDL cholesterol particles. When a few other lab studies like a lipoprotein(a) level and a high sensitivity C-reactive protein (hs-CRP) level are measured, the actual risk can be determined much accurately. Some people do not need any therapy when the advanced labs are evaluated.
3) Am I eating a cholesterol-lowering diet?
The response to changing diet on the cholesterol panel is variable but some patients can lower their LDL-cholesterol level by 100 mg/dl and drop their dangerous LDL particle number by over 50%. The preferred diet is mainly or exclusively of plant foods (fruits, vegetables, legumes, and whole grains), rich in colors and fiber, and naturally low in added salt, sugar, and oils. Patients are asked to read The Plant-Based Solution written by Dr. Kahn and try the dozens of recipes.
4) Should I try a “statin” medication?
Since 1987, drugs ending in statin have been available including the most popular atorvastatin (Lipitor) and rosuvastatin (Crestor). Studies with 100,000s of patients that those with atherosclerosis may benefit from statins. Although most patients do not have side effects, the risk is real and includes aching muscles or weakness, elevated blood sugar, and some cognitive decline. Dr. Kahn always combines statins with the vitamin coQ10 to restore depressed levels of coQ10 to normal. People without advanced atherosclerosis on CIMT and heart CT studies usually do not require statins.
5) Should I try ezetimibe?
Although less well known, ezetimibe (Zetia) has been available for nearly 20 years. Unlike statins which lower cholesterol in the liver, ezetimibe lowers cholesterol in the intestines. It has an excellent safety profile and several large studies demonstrate reduced risks of heart attacks and strokes. Ezetimibe can be combined with a low dose statin or even a statin every other day resulting in excellent cholesterol levels without side effects.
6) Should I try a PCSK9 inhibitor?
Over 5 years ago 2 new cholesterol medications were introduced in the USA after extensive testing. They are the brand names Repatha and Praluent and are injected every 2 weeks. They are very powerful in lowering the LDL-cholesterol and may also lower the Lipoprotein(a) level. They are expensive and usually insurance authorization is required demonstrating that statins and ezetimibe either cause serious side effects or were not effective. So far, the safety seems very favorable.
7) Should I try red yeast rice?
Red yeast rice or RYR is a natural agent in a capsule that lowers LDL-cholesterol with a mechanism similar to statin medications. RYR is available in health food stores and at the Kahn Center. In an adequate dosage, RYR can lower cholesterol on par with a statin. RYR is usually well tolerated. Several large studies involving thousands of patients demonstrate that RYR can reduce the risk of heart attacks and strokes
8) Should I try bergamot?
Bergamot is a citrus fruit grown in southern Italy that has been studied for its ability to lower cholesterol and blood sugar. It is in tablet form and is very safe. It can be used alone or in combination with statins, ezetimibe, or RYR. Studies have shown that bergamot helps reverse plaque in carotid arteries.
9) Should I try niacin?
Niacin is vitamin B3 and has been used to lower cholesterol for over 50 years. It has a distinct ability to cause a flushed feeling about 30 minutes after taking a dose. Niacin lowers LDL-cholesterol, raises HDL-cholesterol, and can lower Lipoprotein(a) cholesterol so it offers a powerful combination effect. Niacin has fallen out of favor a bit combined with statins but it is used alone or with other agents at the Kahn Center in patients with an elevated Lipoprotein(a) level.
10) Should I try garlic?
Yes, aged garlic is odorless and is available in tablets. Studies demonstrate that aged garlic lowers cholesterol and blood pressure. Several studies from UCLA also show that aged garlic can reduce the amount of plaque volume in heart arteries, no small feat! Garlic can be combined with other agents, is safe, and is inexpensive. And it does not make you smell of garlic.
