Q: At our last checkups, my husband's LDL was 147, and his HDL was 70. He doesn't know his total cholesterol. My LDL was 157, my HDL 77, and my total cholesterol was 254. But only my husband was prescribed a statin. Is there a reason for this, other than that we have different doctors? A: Although cholesterol is but one of a myriad of risk factors that lead to atherosclerosis, or hardening of the arteries, it's one that can be changed with medications — with some experts believing that a large portion of the population should be taking these medications to prevent a heart attack or stroke. However, the science is somewhat nuanced as to who precisely might be the best candidates for cholesterol-lowering medication. The question to ask: Does your husband have other risk factors for atherosclerosis that you don't? This may not be applicable to you or your husband, but smoking cigarettes is one of the greatest risk factors for heart disease. Women who smoke 20 cigarettes per day have a six-times-higher risk of having a heart attack than those who have never smoked. Men have a three-times-greater risk. Other independent risk factors for heart disease are: high blood pressure; diabetes; a history of early heart attacks among immediate family members; elevated levels of an inflammatory marker called cardiac CRP; age; obesity; kidney problems; and, of course, gender. Men simply have a greater incidence of heart attacks than women. Now let's look at the numbers. Both you and your husband have a high HDL, the so-called "good" cholesterol. People with low HDL cholesterol (less than 40 in men and less than 50 in women) have a greater risk of heart attacks. Elevated LDL, the so-called "bad" cholesterol, is an independent risk factor for atherosclerosis. Studies have shown a decrease in heart attacks and strokes in those with risk factors for atherosclerosis who lower LDL cholesterol with medication. Many doctors use a calculation based on age, HDL cholesterol, total cholesterol, diabetes, high blood pressure and smoking history to determine a 10-year risk of having a heart attack, stroke or heart failure. The assessment that these doctors make is this: If the calculation shows that a person has a greater than 7.5 to 10 percent risk over a 10-year period, then they should be on a medication to lower cholesterol. Your husband's risk, based on other factors, may have put him at a level for which treatment was deemed necessary. That said, the science behind the risk calculator is not strong and is, in fact, based on older data. A recent study published in the Journal of the American College of Cardiology tracked 307,000 patients from 2008 through 2013 — complete with a five-year follow-up — and found, preliminarily, that the assessment calculators significantly overestimated risk. Thus, many patients may be placed on statins based on an inaccurate calculation. To your point about physicians, however, some doctors are indeed more likely to treat an elevated LDL cholesterol than others. So, while your husband may have other risk factors that would lead a physician to prescribe a statin, if you're still concerned about your cholesterol numbers, I would suggest you discuss this with your physician. Robert Ashley, M.D., is an internist and assistant professor of medicine at the University of California, Los Angeles. Send your questions to firstname.lastname@example.org, or write: Ask the Doctors, c/o Media Relations, UCLA Health, 924 Westwood Blvd., Suite 350, Los Angeles, CA, 90095. Owing to the volume of mail, personal replies cannot be provided.
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