Keeping Your Heart Healthy: What Is All the Fuss About Cholesterol?

Jonathan Greene, MD, discusses why cholesterol is such a core component in cardiovascular health. He shares why some patients do well on cholesterol medication but others can improve cholesterol levels with lifestyle modifications.
Keeping Your Heart Healthy: What Is All the Fuss About Cholesterol?
Featured Speaker:
Jonathan Greene, MD
Dr. Jonathan Greene is a cardiologist in Concord, MA, and is affiliated with Emerson Hospital. He received his medical degree from Tufts University School of Medicine and has been in practice nine years. He specializes in echocardiography, nuclear cardiology, and preventive cardiology and is experienced in echocardiography, nuclear cardiology, preventive cardiology, exercise stress testing, and cardiac ct. 

Learn more about Jonathan Greene, MD
Keeping Your Heart Healthy: What Is All the Fuss About Cholesterol?

Michael Carrese: If you take a drug to manage your cholesterol levels, you're in good company. Millions of Americans are on the mainly medications called statins and they have been for decades. But there are studies that suggest some who are taking them really don't need to be doing so. And many others who could benefit from statins are not getting the prescription. So we're going to try to sort this important issue out today with Dr. Jonathon Greene of Emerson Cardiovascular Associates. This is Health Works Here. The podcast from Emerson Hospital, I'm Michael Carrese. And Dr. Greene, Perhaps it would be best to start with reminding everybody what cholesterol is exactly, and why it gets so much attention?

Dr. Jonathon Greene: So cholesterol is a byproduct of the body that is directly related to the amount of plaque in the arteries and is associated with heart attacks and strokes. So if you have a lot of circulating bad cholesterol, it can increase the amount of plaque in those arteries and those plaques can cause heart attacks and strokes. However good cholesterol numbers can help reduce the amount of plaque in the body.

Host: And not all the cholesterol in the food we eat is bad either. Right?

Dr. Jonathon Greene: No, that's exactly right. Some of the cholesterol in food is not associated with poor outcomes. And figuring that out has been a challenge over the last 40 years.

Host: So as I mentioned, there's some discussion in the medical community about who should be taking these medications to manage cholesterol. And I'm just wondering if you could break down the categories of patients that we're talking about here.

Dr. Jonathon Greene: I think the first step is to separate the population into two groups. If you've had a heart attack or a stroke or you have diabetes or you're actively smoking, you need to be on a cholesterol medication because the benefits of those medications really is not questioned in the cardiac literature. The bigger question is patients who have not had any of those issues and for patients who have never had a heart attack or a stroke or diabetes, it's really an individualized decision between the doctor and the patient depending on who that patient is, and what their numbers are. So for example, in 2013 we changed the way we manage cholesterol. We used to just say if your number was above a certain amount, you should be on a cholesterol medication. But now we take the whole patient. And so if you have a patient in your office who is a certain age and has certain risk factors, they may need a cholesterol medication. However you have that same patient and they don't have certain risk factors, they may not need cholesterol medication even with the same numbers.

Host: And what are the risk factors that you pay most attention to?

Dr. Jonathon Greene: So high blood pressure is one, actually ethnicity is another piece of the component. The age is probably the most important determinant. And then the presence of diabetes or smoking can really impact whether someone needs a cholesterol medication.

Host: Talk about the age factor a bit more. When do you start to pay more attention to cholesterol?

Dr. Jonathon Greene: We usually start making these calculations once a patient reaches age 40. At the 40th birthday in the doctor's office, that's when we have this risk assessment to determine whether cholesterol therapy needs to be thought about.

Host: As I mentioned at the beginning, people have been taking statins now for decades, so if you take a look at the big picture, what is it that we know now about its effectiveness and the possible risks and downsides of lots and lots of people being on cholesterol medications?

Dr. Jonathon Greene: I think that something to start off with is that in 40 years of cardiovascular research, one thing that we know to be true after all millions of patients of data put together is that there's a direct association between the level of bad cholesterol and the amount of heart attacks and strokes. And this is not debated in the cardiology community that the higher the bad cholesterol on average is associated with a higher risk of heart attacks and strokes on average. The question is who needs to be on these medications if they haven't had a heart attack or stroke? And the debate centers around the fact that we know that patients who go on these medications have lower risks of heart attack or stroke, but it's a small number, absolute number. And so that's where the calculation gets made when to put a patient on medication.

So for example, let's say I have a patient in my office and I calculate their risk of having a heart attack or stroke over the next 10 years is above 20%. My recommendation is going to be to place that patient on a cholesterol lowering medication to reduce that risk over the next 10 years. But that's a commitment for the patient to take the medication for 10 years to have that benefit. And over 10 years there is a risk of side effects and we're also finding out that more and more people are benefiting from statins, but that means treating a lot more patients.

Host: What are the main side effects to worry about?

Dr. Jonathon Greene: Most common side effect is muscle aches. In clinical trials, the number is around 3% of patients. However, in observational trials, it's closer around seven to 8% of patients. Satins are generally very safe. We have millions of patients in America on them and they're probably the most important medication we have aside from antibiotics for improving the life expectancy of Americans. So these risks need to be taken in context of the benefits of the medication. Rare side effects include liver problems, and one question that I always get asked about is whether memory loss is associated with statin therapy. And the answer to that question is the jury is still out.

Host: Are there any cumulative impacts to being on statins for a long time?

Dr. Jonathon Greene: Not that we have seen in current studies and we have, we don't have studies that have gone on for 30 years that are randomized, but observationally we have not seen that.

Host: So of course is not the only option. You can make headway with cholesterol levels with diet as well. So what's your main advice for folks about using diet to improve their cholesterol?

Dr. Jonathon Greene: So we know that bad cholesterol comes from animal products and animal byproducts such as dairy and butter and also from lobsters and shellfish and shrimp. So the main way to reduce the amount of bad circulating cholesterol in the body is to reduce the intake of these parts of the diet.

Host: And generally speaking, how effective are dietary changes and do they accomplish as much as the medications do?

Dr. Jonathon Greene: I typically quote to patients that diet will lower the bad cholesterol numbers by a maximum of around 30% with intensive dietary modification. Now the number may be a little bit higher if you go completely vegan, which would be a complete elimination of animal products and animal byproducts. But the best way to do this according to the American College of Cardiology, is to go with a Mediterranean diet, which has been found to lower the risk of cardiovascular disease.

Host: I also wanted to ask you about another common medication used for heart issues, which is aspirin, because there's also been some discussion in the medical community about that and rethinking its use. So where does that stand?

Dr. Jonathon Greene: So this is recently changed. Last year the American College of Cardiology changed our recommendations regarding aspirin. And the reason for this is because now that so many more patients are on statins, the benefits of aspirin when combined with satins is much less so. We used to think that aspirin was this great drug that prevented heart attacks and strokes, but when patients are taking both aspirin and statins, that benefit of aspirin is slightly mitigated and the risks of aspirin are still there. So when you weigh those risks and the benefits of the aspirin, now the pendulum has kind of swung to discontinuation of aspirin in patients who have not had a heart attack or a stroke. Because the benefits of statins are kind of overtaking the benefits of the aspirin. What I like to say to my patients is that statins are the new aspirin.

Host: Wow, that's a pretty dramatic statement. What are the main risks with aspirin?

Dr. Jonathon Greene: The most important risk is bleeding and the risk of bleeding, I think if more than we used to think it was in the past. And when you take that calculation, the benefits are really not there to justify the risk in patients who otherwise have not had a heart attack or a stroke or don't have a need for aspirin for any other reason.

Host: You know, so it seems to me that this all points to having a discussion with your doctor about your individual situation as opposed to going with what has been the formula, quote unquote, if you will for so long about who should be on cholesterol medication and who should be taking aspirin.

Dr. Jonathon Greene: That's exactly right. It's an individual decision between the doctor and the patient and each patient is different.

Host: So if you had to boil down to just two things, the best advice you give to people about keeping cholesterol low and keeping your heart strong. What are those two things?

Dr. Jonathon Greene: Well, I like to quote Michael Pollan with this. And in terms of a diet, I recommend eating real food, mostly vegetables and not too much. And then for exercise, my recommendation is to sweat for 150 minutes per week to keep the heart strong.

Host: So be a little more specific about that. Do you mean working up a really good sweat or are you talking more about just, you know, starting to perspire and work a little bit?

Dr. Jonathon Greene: Exactly. Exactly. Our recommendations are defined as moderate intensity exercise and the way we typically defined that as just starting to get your, you know, just starting to get the blood circulating and getting some sweat going.

Host: So shifting gears for a minute, Dr. Green, I always like to ask physicians and other providers what drew them to a particular field because there are so many different kinds of medicine that you can practice. So why did you end up in cardiology?

Dr. Jonathon Greene: I find the heart so fascinating. It's just this amazing organ and, you know, it's an organ that really, as we get older just can, you can develop a lot of diseases with it. And I love improving the quality of life and life expectancy in the community that I live in.

Host: And what is it that you love about this job day in and day out?

Dr. Jonathon Greene: I love being able to educate my patients about, you know, lifestyle changes and seeing them in the office for follow-up and seeing that, you know, they've really taken our discussions literally to heart and have started changing the way they, you know, eat, changing the way they exercise. And I know that those patients are doing themselves a really great service.

Host: And you've done some good educational work here today as well on this program, but I'm afraid we're going to have to leave it there. I want to thank my guest, Dr. Jonathon Greene with Emerson Cardiovascular Associates. To schedule an appointment with Dr. Greene or other Emerson physicians. Please visit or you can call (978) 287-8767, that's (978) 287-8767 to reach Emerson Cardiovascular Associates. If you found this podcast helpful, please share it on your social channels and check out the full podcast library for additional topics that may be of interest to you. This is Health Works Here, the podcast from Emerson Hospital. Thanks for listening.