Hypercholesterolaemia, i.e. elevated LDL cholesterol, affects every second Pole and is the main risk factor for the development of cardiovascular diseases. And these, in turn, are the most common cause of death (43,3%) in Poland. We are talking about the problem with prof. dr hab. Przemysław Mitkowski, MD, President of the Polish Society of Cardiology.
Medonet: What is hypercholesterolaemia?
Prof. dr hab. Przemysław Mitkowski, MD, PhD: It would seem a very simple question. In practice, this is not so. The values of the norms of cholesterol, and in particular the “bad” cholesterol, that is LDL cholesterol, depend on the clinical situation of a given patient (they have recently decreased). So we never judge value itself.
Hypercholesterolaemia is, simply put, increased levels of cholesterol in the blood, especially its LDL fraction, also known as “bad cholesterol”. Cholesterol is a compound that is a very important building block of all our cells, as it is an integral component of cell membranes. On its basis, sex hormones are also synthesized, so it is extremely important for our body. However, if there is too much of it, especially in the LDL fraction, problems begin. It is “toxic” and too high a level causes it to accumulate in the walls of the vessels – mainly arteries, causing local inflammation, which in turn causes, firstly, an attempt to break down and thus remove this cholesterol from the vessel wall, and secondly, where it is located (inflammatory cells “inflow” and smooth muscle cells, collagen fibers appear, limiting the place where cholesterol is deposited, causing the lumen of the vessel to narrow).
However, we must remember that these processes are also aimed at stabilizing the plaque. The idea is that a thick “cap” is formed over the nucleus of liquid cholesterol-containing lipids (the nucleus of the lamina). Then the atherosclerotic plaque is less prone to cracking. And as we know, its rupture can lead to clotting, initially with platelets, then fibrin deposits. As a consequence, even within a few minutes, vessel occlusion, distal ischemia and myocardial infarction can occur.
Which test results should be of concern to patients?
Total cholesterol is not that important. We are primarily interested in LDL cholesterol. It is important that it does not exceed 115 mg / dl even in people with low cardiovascular risk. This year’s guidelines of the European Society of Cardiology even indicate a value of 100 mg / dl for this group as possible to consider after taking into account other factors. For those who are more burdened, the LDL cholesterol value should be even lower. The previous recommendations considered the LDL cholesterol concentration of 115 mg / dl as a common norm, and even earlier at 130 mg / dl. As can be seen, there is a progressive decrease in this value. Scientific data show that the lower the cholesterol, the lower the risk of progression of atherosclerosis in the vessels.
We must be aware that in infants and young children, LDL cholesterol levels are between 40 and 60 mg / dl, which is very little. This is enough for their proper growth and development.
I eat fatty foods = I have high cholesterol. Truth or myth? Where does cholesterol in the blood come from?
Cholesterol consumption does not directly translate into its concentration in the blood. High its level is largely determined by genetic predisposition, but it does not mean that a fatty diet does not increase cholesterol levels. Among the factors that are responsible for the development of hypercholesterolaemia, we mention, inter alia, age, obesity, high-fat diet, lack of exercise, smoking, excessive alcohol consumption, as well as certain diseases (e.g. diabetes, kidney failure or hypothyroidism). As a result, cholesterol consumption does not translate directly to disease development, but a diet high in fat may increase cholesterol levels.
It should be remembered that dietary cholesterol, or more precisely its pool in the body, does not exceed 5-10 percent. all cholesterol.
Can slim people struggle with the problem of hypercholesterolaemia?
Unfortunately yes. It must also be admitted that in these people the treatment of hypercholesterolaemia is much more difficult. We cannot, for example, change our lifestyle, i.e. reduce cholesterol levels. In slim people, we have practically no other means of action than administering drugs that lower LDL cholesterol. In obese people, losing weight by every 10 kilograms will lower our cholesterol levels. And it is crucial to try to reach the recommended body weight.
Why is the lipid profile still too rare? Why is systematic examination so important?
Each of us, as soon as we turn 40, and there are no other risk factors (e.g. family hypercholesterolaemia) or suffer from other diseases (then much earlier), should perform a set of preventive and biochemical tests, including cholesterol determination with all his factions. If this concentration is correct, the next test should be performed no later than in 5 years. Somewhat earlier, when these values approach the thresholds for which pharmacological intervention is necessary.
It is estimated that approx. 61 percent. Poles have hypercholesterolemia. Unfortunately, this disease does not hurt. It does not cause any discomfort until it develops diseases such as stroke, heart attack and intermittent claudication (the patient is not able to walk 100-200 meters without experiencing leg pain).
I think all Poles know what cholesterol is. They realize that it contributes to heart attack and stroke, but they don’t want to diagnose it. Elevated cholesterol levels do not cause symptoms within a week or even several months. It’s a long process spanning a decade or two. Therefore, when it comes to prophylaxis, we mark the risk individually on the basis of simple parameters, such as gender, age, blood pressure and cholesterol concentration.
The risk of serious atherosclerotic events in a 40-year-old (even when all the parameters mentioned above are elevated) is negligible. It is worth showing such a patient what the risk of a cardiovascular incident will be at the age of 60, if he / she maintains the above-mentioned parameters at the current level. And then it turns out that among smokers, with high blood pressure and high cholesterol, one in two will die within the next 10 years. Appropriate prevention will affect many aspects of his life, including freedom, mobility and dependence on other people’s help.
What are the consequences of untreated hypercholesterolaemia?
First of all, a heart attack. This is the most common complication associated with persistently elevated cholesterol levels. The worst part, however, is that the changes are noticeable in many coronary vessels. They are constricted, but not yet to the extent that it would lead to a heart attack. However, this disease is progressing. We have symptoms only when it is very advanced, i.e. when the diameter of the vessel is narrowed above 70%. Other consequences of untreated hypercholesterolaemia are strokes and circulatory disturbances in the lower limbs. Heart failure develops after the infarction, which further reduces exercise tolerance and daily activities. All this shortens life and significantly reduces its comfort.
Can we protect ourselves from the disease or reverse it?
We cannot protect ourselves from the very predisposition to hypercholesterolaemia, but we can protect ourselves from its effects by effectively lowering blood cholesterol levels. However, we do not treat cholesterol, but the patient. Therefore, we first need to determine what its risk is. If it is low, according to the recommendations of Polish scientific societies, it is enough for the LDL cholesterol value to be at the level of 115 mg / dl. However, if the risk is high, then we aim for it to be below 70 mg / dl. However, a patient after a heart attack or stroke is a big problem. Then we want LDL cholesterol to be lower than 55 mg / dl. The worst situation concerns a patient who has had at least two heart attacks in the last two years. In such cases, recent recommendations say that this LDL cholesterol should be below 40 mg / dL. It is very difficult to achieve such a level.
However, we have a wide range of drugs, from popular statins and the products that we combine with them. Recently, completely new treatment concepts have emerged that rely on the administration of drugs by injection. They stop the synthesis or inhibit the protein (PCSK9), which is responsible for the breakdown of receptors for LDL cholesterol particles on the surface of liver cells. These drugs are reimbursed for patients covered by drug programs.
The first of them concerns familial hypercholesterolaemia, i.e. a genetically determined disease in which there is a deficiency of LDL receptors. Such people experience strokes and heart attacks at a very early age (3-4 decade of life). The second program is dedicated to patients after two atherosclerotic episodes in whom it is impossible to lower cholesterol using traditional drugs. We are trying to convince the Ministry to lower the strict criteria a bit so that more patients could be included in these programs.
How to protect yourself from disease?
Prophylaxis is the answer. First of all, a low-sodium diet. We shouldn’t salt that much. The salt that is already in the dishes is more than enough. Canned foods should also be avoided. Even some drinks contain sodium benzoate. Reduction of animal fats in favor of vegetable fats. Limiting alcohol consumption. Eating whole grains, fruits and vegetables. And traffic. It’s not about moving around the house every day. We want to take a brisk step, at least 30 minutes 5 times a week. You cannot forget about chronic stress – it is worth taking action to lower its level. Stress also affects lipid metabolism.
Although hypercholesterolaemia affects almost every second of us, in most cases it is detected as a result of the first cardiovascular event, such as a heart attack or stroke. What is the situation of these patients?
The KOS-Zawał program provides a certain facilitation for the care of these patients. It was developed jointly by the Ministry of Health and the Polish Cardiac Society. It is a comprehensive care program, thanks to which patients have already scheduled follow-up visits after leaving the hospital due to a heart attack. During the visits, not only is their health assessed, but we also check whether they are taking their medications as prescribed. Every heart attack patient, regardless of their cholesterol value, must take a statin for the rest of their lives. There are no exceptions to this. After 3-4 months, the concentration of LDL cholesterol is determined and, if necessary, we adjust the treatment to achieve the values recommended in the recommendations for a given group of patients.
Unfortunately, the sick leaves the program after a year. And here comes the task for primary care physicians, outpatient specialist care – it is necessary to monitor cholesterol levels. Unfortunately, sometimes I have the impression that the knowledge of these standards, depending on the clinical state, in the medical community is not sufficient. This worries me.
Why is the problem of hypercholesterolaemia such a big challenge, why do patients stop treatment even though the consequences of neglecting treatment are so severe?
The so-called “Black PR” on drugs that lower cholesterol. I am sure about that. Everyone in Poland considers himself to be a well-educated doctor. As a society, we rely on suggestion, untested and scientifically unsubstantiated information. In classical medicine, we rely on the results of randomized trials conducted on thousands of patients, one group of whom received active treatment, while the other group received the same tablet without the active substance.
Additionally, neither the patient nor the doctor who conducts this test knows what is in the package. Based on the results of such studies, we know that those who take statins live longer. Of course, side effects may occur to a slight, non-statistically significant degree. The benefits of statin treatment are therefore indisputable. Anyone who claims they are ineffective or harmful is responsible for deaths caused by hypercholesterolaemia. This should be emphasized very strongly.
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The material was created in cooperation with Novartis