The importance of cholesterol in heart disease

This month is National Cholesterol Month and I thought it was timely to question whether concentrating on cholesterol in terms of health improvement has been a good thing over the years. The importance of cholesterol in heart disease was first established many years ago, in patients with the monogenic condition, familial hypercholesterolaemia. If you had cholesterol readings that were extremely high in a family that was known to record heart attacks in young people, reduction of the cholesterol had a dramatic and beneficial effect. These early observations transformed the future management of this condition.

It was not long before these observations were extended to patients who did not have that high a total cholesterol or that bad a family history of early heart attacks, who were also shown to have their life expectancy substantially improved with lowering of their cholesterol – and usually this refers specifically to the bad or LDL cholesterol. The MONICA study dramatised the benefits of this in the improvement of heart disease shown in Western Europe. Before the introduction of statins, strict low cholesterol and low saturated fat diets and even cleaning the blood of LDL cholesterol were all successfully used but the use of statins, now generic and cheap, were a game changer.

The situation in 2022 now, is that we have moved forwards and LDL cholesterol, the harmful one, can now be reduced to almost zero in any patient whose risk of arterial disease is severe or life-threatening. This now leaves us looking at what we call “residual risk” and the factors that influence arterial disease that are not directly connected with LDL cholesterol. We know for example that inflammatory factors, not influenced by LDL lowering, are contributory to cardiovascular events. We know that small dense LDL cholesterol is worse than large LDL cholesterol. We know that patients who have a raised lipoprotein (a), a genetic risk factor, have increased risk of cardiovascular events which are not treatable by current medication options. We know that there are numerous polygenic risk factors that contribute to cardiovascular risk and until recently, these have remained unknown contributors to cardiovascular events. This is an exciting time for heart disease prevention as we look beyond cholesterol for answers, and being alert to the world outside cholesterol, is proving to be helpful to patients known to be at risk.

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