To the Editor: Doctor faults some healthy heart tips
Written by W.E. Feeman, Jr, M.D.   
Wednesday, 03 February 2010 09:57
The tips for maintaining a healthy heart, as promoted by the American Heart Association and published in the Sentinel-Tribune on Jan. 20, are in error - at least as far as cholesterol is concerned, and more likely to fail in men.  I write this letter to combat the complacency that will likely set in when men look at a total cholesterol (TC) of 199 mg/dl or less as a reason not to be concerned about their cholesterol.
TC, as a risk factor for atherothrombotic disease (or ATD, such as heart attacks or strokes), became passe' over 30 years ago.  Indeed, about 28% of my patients who suffered some clinical ATD event had TC of 199 mg/dl or less.  The reason why is that TC is made up of LDL ("good") cholesterol, HDL ("bad") cholesterol, and the cholesterol carried by triglycerides.  People with low levels of HDL will therefore have lower TC, and low HDL is one of the leading causes of ATD.  
This scenario is more likely to occur in men, but is becoming more common in women.
I will cite a horrific case from my files, involving a middle-aged man who suffered a massive stroke despite a TC of 200 mg/dl.  He had a very low HDL and the cholesterol that accumulated in his arteries did so in one of the main arteries to the brain, leading to the stroke and ruining his life.  (He was not a patient of mine prior to the stroke.)
I have advocated the use of lipid ratios to predict the population at risk of ATD.  The best lipid predictor is the Cholesterol Retention Fraction, defined as  [LDL-HDL]/LDL.  The above patient's CRF was in the highest risk group, despite his "optimal" TC.
My advice is to ignore TC and rely on CRF.  If your CRF is 0.80 or greater, your ATD event is likely to occur in your 40s; if your CRF is 0.75-0.79, in your 50s; if your CRF is 0.70-0.74, in your 60s; if your CRF is 0.60-0.69, in your 70s; but if your CRF is 0.59 or less, then not till your late 70s.   Cigarette smoking accelerates the average age on ATD onset in younger patients, as does high blood pressure in older patients.  The actual LDL level also influences the average age of AD onset.  
W.E. Feeman, Jr, M.D.
Bowling Green

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