Stephen Sinatra

Stephen T Sinatra M.D., F.A.C.C.

Heart Health

Sorting out the "multiple personalities" of Cholesterol

Cholesterol's "multiple personalities"

Posted Mar 05, 2009

Glenda is one of my nurses. She approached me recently to ask about her cholesterol. She was concerned because her family doctor wanted to give her a prescription for Lipitor, the popular cholesterol-lowering drug. Her blood test results had come in, showing her total cholesterol at 271 and LDL at 165. By standard measures, those levels are considered "high."
Hold off on the prescription, I said to her, and recommended she take a new, more comprehensive lipid test now available to doctors. There are two of them to choose from: the VAP test (short for vertical auto profile), developed at the University of Alabama, Birmingham (UAB) Medical Center, and the Lipoprotein Particle Profile test offered by SpectraCell Laboratories in Houston.
These tests are a boon for doctors and not just cardiologists. I've been practicing cardiology for 35 years and have lived with the cholesterol-as-the-devil story that whole time. What you see and hear about cholesterol on TV and read in the newspapers is generally all nonsense. The "official" line about how high is your cholesterol is pretty much irrelevant. Numbers are misleading. Half the people who die from heart attacks have "normal" cholesterol levels.
To get a relevant picture of disease risk from your cholesterol, the standard lipid profile tests that most doctors perform really come up short. Just testing totals of cholesterol, high density lipoproteins (HDL), and low density lipoproteins (LDL) doesn't tell you enough. Such monitoring is probably only 40 percent accurate in predicting risk for heart attack. More information is needed if we are to utilize blood lipids as a reliable risk assessment. Thanks to medical science, we now have better tests that can break down the many components of cholesterol, and most importantly, single out the most dangerous fractions. You can now get a much more accurate picture of what may or may not be a cholesterol problem.
Here are just a few of the key readings these tests give you that the old test doesn't:
● Your LDL Components
Higher levels of LDL are considered to increase the risk of heart attack and necessitate treatment. But LDL, for the most part, is really a good guy-a sheep slapped with a wolf's reputation. Your basic cholesterol is none other than LDL-a fatty substance produced in the liver and wrapped in a protein coating that allows it to circulate in the bloodstream. It performs absolutely essential services in the body as a raw material. Enzymes convert it to vitamin D, steroid hormones (like estrogen, progesterone, testosterone, and cortisol), and the bile acids needed for digestion. LDL does have multiple personalities, however, and the new tests nicely identify who's who. LDL becomes dangerous when it is oxidized or overly present as a small dense particle as opposed to a larger, fluffy more "buoyant" particle.
● Your Lp(a) Level
The tests monitor a subtype of LDL called Lp(a). When this substance rises abnormally in the bloodstream, the result of a genetic flaw, it can increase the risk of heart attack up to 25 times. I consider it to be the most dangerous form of cholesterol, a highly inflammatory and thrombotic agent. There is no conventional medication for it Lp(a), but niacin (vitamin B3), high dose vitamin C, nattokinase (a supplement made from the Japanese soy dish natto), and fish oil will help neutralize it. I have seen many patients with normal cholesterol and high Lp(a) who have had coronary disease. Anybody with a family history of cardiovascular disease needs to check out their Lp(a) level.
● Your HDL Subtypes
A high level of HDL-the so-called good cholesterol-is generally associated with protection against heart attack. We now know that HDL is further classed into subtypes HDL1 and HDL2. Both reduce risk, and in the new tests, you get a measurement for both. The difference between the two: HDL2 is far superior to HDL1 in providing protection for the heart.
● IDL (Intermediate density lipoproteins)
This is a type of blood fat that represents an inherited independent risk factor for heart disease. I had never heard about this substance until recently, so even old dogs like me can learn new tricks.
● Triglycerides fractions
Previous blood tests give you a total triglyceride level, and anything above 180 is considered abnormal. With these tests, various triglycerides are singled out. The one to be concerned about is called VLDL3, the most inflammatory triglyceride, considered a prime indicator for coronary artery disease progression, insulin resistance, and type II diabetes. Triglycerides are fat globules in the bloodstream. In a concentrated form, they create the fatty "love handles" around your midsection.
To see how these tests can make a difference, let's return to my nurse, Glenda. The VAP test revealed her LDL mostly of the large, desirable particles. Her HDL fractions strongly favored the superior kind. Her IDL level was low, in the range where you want it. The test, however, showed her Lp(a) somewhat elevated. In reviewing her results, I felt the only thing needing improvement was Lp(a), so I recommended Glenda take some niacin, nattokinase, and fish oil.
If her regular doctor had put her on a statin drug, as he wanted to do to lower her cholesterol, the drug would have had more potential to do harm than good. Statins drive up Lp(a), and, of course, deplete the body of CoQ10, a natural substance produced in the body that is critical for cellular energy. It is this depletion that causes muscle pain, a common side effect with statins.
By way of example, here's another patient of mine who was helped by these tests. Dave had a history of heart disease. His results showed a high level of VLDL3 (the inflammatory triglyceride) and an excess of small dense LDL particles. His case warranted prescribing a potent anti-inflammatory medication like a statin. He had a threatening cholesterol profile and not just a vague count of total cholesterol.
You can readily see the major benefits from these advanced cholesterol tests just from these examples, and understand why I urge you to take advantage of them when you have a checkup. My hope is that these tests, as they become more and more popular, will put the brakes on the runaway statin prescribing mentality affecting doctors today who pull out the prescription pad at first sight of elevated cholesterol.
The bottom line: when your doctor talks about getting your cholesterol checked, ask for the VAP test, or the SpectraCell test. For more information on these tests, which are covered by Medicare and most health insurance plans, go to the following web sites:,

About the Author

Stephen Sinatra

Stephen T. Sinatra, M.D., F.A.C.C., specializes in metabolic cardiology and is the author of the monthly newsletter Heart, Health & Nutrition.

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