Cardiovascular Disease

Ask the DOC

Cardiovascular disease (CVD) is a huge burden on global health despite decades of focused research and intervention. Multiple large studies have demonstrated that low HDL (“good cholesterol”) levels and high LDL (“bad cholesterol”) levels are both strongly associated with an increased risk of CVD. One large study showed that there was a five to six percent reduction in vascular events for every 10 mg/dl decrease in LDL. It is on the basis of this and other studies that major international cardiology and lipid associations recommend statins (Lipitor, Crestor, etc.) as first line treatment for treating elevated lipid levels (aka dyslipidemia) as a risk factor for CVD. However, as there is considerable variation in people’s responses to statins, other non-statin medications are also recommended by current guidelines.

A number of studies have shown an inverse relationship between HDL levels and CVD. Therefore targeting raising HDL levels has been proposed as a means of reducing CVD risk. The problem is that statins, while they lower total cholesterol and LDL levels, do not raise HDL levels. A low-fat diet and proper exercise may elevate HDL a bit, but there is only one medication that raises HDL levels and that is niacin, aka Vitamin B3. Niacin may lower total cholesterol, triglyceride, and LDL by small amounts, but its main effect is raising HDL. The main side effect of niacin is skin flushing, or the feeling that your skin is on fire. This relatively common side effect can be lessened or eliminated by taking a non-coated aspirin with the niacin or using a slow-release niacin product like Niaspan. Niacin is also associated with an increased risk of new-onset or worsening diabetes, gastrointestinal distress, and muscle pains and aches.

It is interesting to note that a number of studies have shown that despite niacin causing a significant increase in HDL levels, it was not associated with a decreased risk of death, heart attacks, and strokes. This confusing outcome obviously requires more study. It is thought that part of the reason may be that there are a number of sub-types of HDL and perhaps niacin affects a sub-type that is not linked to CVD. The jury is still out but it is becoming clear that current lipid testing is insufficient to determine the levels of the sub-types of not just HDL, but all the lipids. Research is ongoing to determine how all these sub-types affect the human body.

In most cases, lipid levels are primarily determined by a person’s genetic background. Families with early CVD, like strokes and heart attacks at a young age (below 50), often have very low HDL levels (below 20) and very high LDL levels (above 190). Despite there being little evidence that niacin affects mortality and CVD, most practitioners would place people in this category on both a statin and niacin and would perform frequent cardiovascular testing. So if you don’t know what your lipid levels are get tested and start at a young age (below 40) to create a baseline. Assessing your risk of CVD and doing something about it are vital to staying alive longer and staying healthy.

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