Measure LDL particle number (LDL-P or ApoB) instead of just LDL cholesterol (LDL-C) to accurately assess cardiovascular risk, as the particle itself, not just the cholesterol mass, is the causal agent for plaque formation.
Recognize that LDL is a causal factor for heart disease, and lowering it is generally beneficial for reducing risk. However, remember that LDL particle number is the true causal agent, and LDL-C alone may not always reflect risk or treatment benefit.
Consider very low LDL levels (e.g., 10-20 mg/dL) as safe and beneficial, based on genetic evidence from individuals with lifelong low LDL due to PCSK9 loss-of-function mutations who do not develop heart disease.
Actively address metabolic syndrome, characterized by high triglycerides, low HDL cholesterol, and a predominance of smaller LDL particles, as it is a significant underlying factor for cardiovascular disease.
Focus on reducing visceral fat, especially around internal organs, as it is a prevalent underlying factor contributing to metabolic syndrome and overall cardiovascular disease risk.
Monitor C-reactive protein (CRP) levels as a marker for inflammatory risk, and aim to lower both LDL (or LDL-P/ApoB) and CRP for maximal cardiovascular protection, as they each contribute to risk.
Educate yourself on the first signs of heart disease, as it is often a ‘silent killer’ with no premonitory symptoms, and early recognition can be critical for intervention.
Be aware that the length of time lipoproteins circulate in the blood (‘residence time’) is critical; longer circulation, especially of smaller or remnant particles, increases their opportunity to cause arterial damage.
If taking statins, monitor glucose levels regularly, as statins can increase the risk of developing diabetes, particularly in women and with higher doses.
If experiencing statin-induced myalgias or concerned about diabetes risk, discuss trying pitavastatin (Livolo) with your doctor, as it appears to have a lower association with diabetes risk and potentially fewer muscle side effects.
Do not abandon statins in favor of PCSK9 inhibitors unless truly statin intolerant, as statins provide additional anti-inflammatory and endothelial health benefits not necessarily replicated by PCSK9 inhibitors.
Consider niacin as a therapeutic option for patients with high Lp(a) and/or a high number of small LDL particles, especially if statin intolerant or if PCSK9 inhibitors are not an option, as it specifically targets these risk factors.
Do not rely on simply raising HDL cholesterol levels as a primary strategy for cardiovascular protection, as clinical trials have shown that increasing HDL alone does not consistently translate to reduced event risk.
If you have very high LDL and are statin intolerant, or if maximum statin therapy is insufficient, consider PCSK9 inhibitors as a potent option for lowering LDL and Lp(a).
If you are an APOE4 gene carrier, exercise greater caution and discuss statin use with your doctor, due to theoretical concerns about potential interactions with brain cholesterol transport, though conclusive evidence is lacking.
For elderly patients (over 75-80) on high-dose statins, discuss with your doctor whether reducing the dose or discontinuing might be appropriate, weighing the benefits against potential long-term risks like sarcopenia.
Pay attention to VLDL remnant cholesterol levels, as these particles are highly pathogenic and often missed by standard lipid panels, especially in hypertriglyceridemia.
For statin-induced myalgias, consider trying ubiquinol (CoQ10), potentially a highly absorbable liquid form, although the evidence for its efficacy in reversing symptoms is not conclusive.
If on atorvastatin (Lipitor) and concerned about diabetes risk, discuss with your doctor if a switch to another statin like pitavastatin or rosuvastatin (Crestor) might be appropriate, as atorvastatin appears to carry a higher risk for diabetes.
For patients with moderately elevated triglycerides (150-400 mg/dL), niacin can be an alternative approach to lowering triglycerides and small LDL.
If using PCSK9 inhibitors, be aware that they primarily lower medium and larger LDL particles, and may have less impact on smaller LDL particles, suggesting a potential complementary role for other therapies in some cases.