I Don’t Want To Know
” I don’t want to know”. That’s the most common answer we get when we ask someone why they haven’t had a heart scan. They say, “I feel fine, my diet isn’t great but my cholesterol is OK. Now you’re going to tell me I have a problem and ruin my day”
The interesting part of that response is that we have all become comfortable with relying on cholesterol levels to tell us if we are at risk or not. Few of us ever say we don’t want to know what our cholesterol level is because it will fill us with dread at the prospect of imminent heart disease. We can continue to think we are immortal if our cholesterol is under 200. If it is too high, well, they have a pill for that now. I can take my pill and go back to feeling immortal again, right?
About three years ago a gentleman named Steve McKee came to see us. In his teens Steve watched his father die of a heart attack right in front of him. He grew up vowing that he would not let that happen to his kids. He did everything right. He ate well, exercised, kept his cholesterol down and didn’t smoke. His heart scan showed that he had severe coronary artery disease anyway.
Initially, the news was hard for Steve to handle. But eventually he came to realize that finding out about the problem probably saved his life. He wrote his very touching story in a book that has just been published, ”My Father’s Heart”. The book tells how his father’s death affected him and how he has coped with finding out that he is at risk too. I highly recommend the book.
Steve’s cholesterol levels were pretty good. It didn’t matter. For the past 30 years we have become increasingly obsessed with cholesterol levels as a predictor for the risk of heart disease. The fact is, it doesn’t really work.
Most heart attacks happen in people who have been told their cholesterol levels are “normal” and don’t require treatment. If you look at the distribution of cholesterol levels in the population you will discover that there is not a big difference between those of us who get coronary artery disease and those who don’t. The graph below shows the data from the Framingham Heart Study. The red line is the distribution of cholesterol levels in the population that developed heart disease. The yellow line is the group that did not. There is not a big difference between the two groups.
In fact, there is so much overlap that just about any cholesterol level you might have puts you in both groups. If your cholesterol is 220 you are in the group that gets coronary artery disease. You are also in the group that does not get coronary disease. Your cholesterol level really does not predict your risk very well.
This may be part of the explanation why a recent study failed to show that a commonly used cholesterol-lowering drug did not prevent progression of atherosclerosis. Cholesterol levels alone are not the problem. It is very likely much more complicated than that. Factors such as inflammation within the developing plaque, injury to the lining of the blood vessel and the movement of cholesterol particles into the blood vessel may be much more important than relatively minor variations of the level of cholesterol in the blood.
The drugs known as Statins have been shown to lower heart risk. They also lower cholesterol. There is some evidence slowly accumulating that may indicate that those are two separate effects. We use the right drug for the wrong reason. In trying to lower cholesterol levels we are serendipitously giving patients a drug that has other effects within the blood vessel wall itself that are much more effective than lowering cholesterol.
Proper diet and exercise also lower cholesterol levels and heart attack risk. But again, those may be two separate effects and one is not the cause of the other. A healthy lifestyle helps to protect you and may coincidentally lower your cholesterol too.
Since Zetia is not absorbed into the body and works mainly in the gut to lower cholesterol without any known effects directly on the blood vessels, it may not be surprising that it failed to have any effect on disease progression.
So, if cholesterol levels don’t really predict your risk for a heart attack and lowering cholesterol levels may not be in itself as protective as we like to think does that mean we should ignore cholesterol entirely? Not at all.
What is means is that we need to move beyond feeling safe and smug just because our cholesterol is low and taking pills just because our cholesterol is high. No one dies of high cholesterol levels. They die of atherosclerosis. If you have atherosclerosis we need to treat it. If you don’t have atherosclerosis, lowering your cholesterol probably does not have very much of an effect on your health.
Steve McKee’s heart scan allowed us to look directly at his arteries and tell that how much plaque was there. We put him on an individually tailored plan with his optimum nutrition, physical activity and medication. His scans show he has stopped making more plaque in his arteries.
In the long run, knowing whether or not you have a problem is what leads to peace of mind. If your arteries are clear, you may not need to treat your cholesterol with medication. Millions of people in this country are on cholesterol lowering drugs but have no coronary artery disease and get little or no benefit from being treated. Millions of other people are heart attacks waiting to happen but are not being treated simply because a blood test gave them a false sense of security.
Read Steve’s book. Then decide if your family might want you to know before the heart attack happens.