Maggie McKay (Host): Welcome to Conversations like No Other: Heart Care, presented by the Heart and Vascular Institute of Valley Health System in Paramus, New Jersey. Our podcast goes beyond broad, everyday cardiac topics to discuss very real and very specific subjects that impact your heart health. We think you'll enjoy our fresh take. I'm your host, Maggie McKay. Thanks for listening.

Today, we have with us Dr. Waqas Malick, Director of Lipids and Cardiometabolic Disease at Valley Health System. Thank you so much for being here today.

Dr. Waqas Malick: Thank you for having me.

Host: Of course. Let's start with what is cholesterol and how does it affect cardiovascular disease?

Dr. Waqas Malick: So, cholesterol is a waxy fat-like molecule found in every cell of the body. Now, your cells can produce their own cholesterol, but you also generate cholesterol from the diet that you eat. That 80% of your cholesterol is determined kind of genetically by your proteins and your metabolism, but 20% is determined by your diet.

Now, when cholesterol is entered into the bloodstream, it's a very waxy fat-like substance So, it can't really travel to blood because you have to think of it as like oil mixing with water. It can't happen. So, there are lipoproteins that exist that carry the cholesterol through the blood to its destination. And so, for example, certain cholesterol lipoproteins carry the cholesterol into artery walls or to the gallbladder to help make bile acid and other lipoproteins will help carry cholesterol to the liver for clearance out of the bloodstream. So as cholesterols carry through the blood, certain particles such as LDL, which is your traditional bad cholesterol helps carry the cholesterol into arterial walls.

Now, over time, the more LDL cholesterol you have, or the more LDL-carrying cholesterol you have, the more cholesterol can get trapped behind those arteries. And that happens in certain contexts, such as inflammation especially, or smoking, diabetes. But in general, the more cholesterol you have trapped between the arteries, eventually that starts protruding into the artery or lumen and causes what we call blockages or stenosis. And the more plaque buildup you have, the more blockages you'll have, and the higher risk you are for heart attack and stroke.

Host: What's the biggest misconception you hear from patients about cholesterol today?

Dr. Waqas Malick: The biggest misconception is that lower is not necessarily better. Now, one of the ways we think about risk is there's two types of cholesterol-based risk. The first is genetic risk. The second is acquired risk. Genetic risk is being born with very high cholesterol levels. So if you're somebody that's very young and you have very high cholesterol levels, you are at much higher risk for developing heart disease over a lifetime, just by the sheer quantity of LDL particles and cholesterol you have that could be potentially trapped in your arteries. Now, the biggest myth I hear related to this is that, "Oh, well, You know, I don't have to lower this because I do everything right, I eat healthy," but your genetic risk might be high.

The second form of risk is what I call acquired risk. Acquired risk is based on stuff that happens over a lifetime. So over time, you've weight, you develop diabetes, you develop obesity, high blood pressure. These factors contribute to what we call a risk profile where we know that if you lower the cholesterol in these patients, there's less risk of trapping cholesterol in the arteries because the number is lower and therefore your risk is lower. So, the biggest myth to me is that cholesterol does not need to be lowered. The risk should be really individualized per person, and assess from there to decide whether or not cholesterol needs to be lowered.

Host: Can you briefly explain the difference between LDL, HDL and triglycerides and which numbers matter most?

Dr. Waqas Malick: LDL cholesterol is the traditional bad cholesterol. It was first really discovered in the 1930s in Scandinavia where families would have this inherited cholesterol buildup in their arteries as well as symptoms of chest pain, and they'd have all these cholesterol deposits in their skin. It was further confirmed in Lebanon in the 1960s, and then in the NIH in the 1970s and '80S, when people with genetically very high LDL cholesterol would have very premature heart disease. And the famous story is of the Nobel Prize winners Brown and Goldstein, having patients who were ages six and eight having heart attacks, because their LDL cholesterol levels were so high.

More recently, we've really established LDL as the foremost risk factor, the most modifiable one. All of our therapies are geared towards lowering LDL. All of our sort of lifestyle interventions are focused on trying to lower LDL, but HDL and triglycerides also play a role.

HDL is your good cholesterol. So, what HDL particles do is they carry cholesterol away from plaque and inflammatory cells, and they bring that cholesterol back to your liver to be cleared. So if you have very low HDL, you're at much higher risk because you have nothing counteracting the bad cholesterol.

And then, triglycerides are a fatty substance. They're mostly associated with metabolic disease. So, I think of them more as a sign of metabolic disease. The higher triglycerides you have. So usually, a normal triglyceride level is less than 150. But as triglycerides climb, they climb for various reasons. We're usually get concerned about metabolic risk. Particularly, fatty liver disease, diabetes are the two that go most hand in hand with higher triglycerides levels. And there's some thought that they contribute risk as well, because when you have high triglycerides, your LDL tends to be smaller, denser, and more what we call atherogenic or conducive to forming plaque.

Host: And which numbers matter most, do you think?

Dr. Waqas Malick: LDL matters the most. Even if you have good HDL, if you have very high LDL, you can still form plaque in your arteries.

Host: Dr. Malick, could you please explain what is a good LDL and how patients should approach it?

Dr. Waqas Malick: So, a good LDL cholesterol concentration really depends on the context of the disease. So, for example, if you are born young with very high cholesterol levels, you have a much longer lead time in forming plaque in your arteries. So, these are the people that have genetic familial hypercholesterolemia. If your LDL is greater than 190, since a very young age, you have a much higher lead time on forming plaque in your arteries and people at same age with you that did not have that.

So usually, for those patients, we like to have at least LDL less than 100. And if there's any signs of plaque forming in their arteries, we usually recommend less than 70 to make sure it doesn't progress.

For the average population, then what we usually take into account is something called the risk score or the PREVENT risk score. What this risk score takes into account is what is your predisposition or likelihood of having disease within the next 10 years and over a lifetime or the next 30 years? Depending on the calculation, and there are many factors that go into this, number one being diabetes, but number two being chronic kidney disease, smoking, obesity, and LDL as well, we make different recommendations.

In general, though, we could argue that based on genetic studies, having an LDL naturally of 70 to 85 or 70 to 90 is really protective of long-term coronary disease and long-term stroke and cerebral vascular disease as well. But if you can't get there naturally through lifestyle, then that's what we usually recommend starting to get there pharmaceutically, once you get to a certain age or risk profile status.

Host: Well, many people have never heard of lipoprotein(a) or Lp(a). What is it and how is it different from LDL cholesterol?

Dr. Waqas Malick: So, Lp(a) or lipoprotein(a) is a genetic cholesterol protein. So, it is entirely genetically determined and not affected by lifestyle. You are born with this concentration and it runs in families. So usually, I recommend checking Lp(a), at least in everybody with a family history of heart disease. And that includes either coronary disease, stroke, peripheral artery disease, or vascular or valve replacement, aortic valve replacement.

But in general, our new guidelines recommend that everyone should have it just checked at least once because it does confer increased risk. So, Lp(a) is a little bit different because it's more atherogenic. So, what that means is if I take one LDL particle and I take one Lp(a) particle, the Lp(a) particle tends to cause more plaque.

And what our studies have shown is that over time, if you look at people with very high Lp(a), they tend to have far more plaque at earlier diseases, far more cardiovascular disease at earlier ages, as well as heart attacks and strokes at earlier ages. So now, we recommend checking in everybody just to make sure you don't have this additional risk factor, because likelihood of having increased risk is much higher.

Host: Why is Lp(a) considered a "hidden" cardiovascular risk factor?

Dr. Waqas Malick: Hidden right now. Because most people aren't aware of it. And that's why, you know, I felt like this podcast was very important to do is to bring awareness to this risk factor. Now, if you look at the national screening rates, they've improved over the last two years. But even then, it's been only 1-3% of patients have ever had their Lp(a) checked in the first place. So, we often don't check it until it's a little bit too late. And so, that's why we call it the hidden risk factor.

Host: Do people with family history of heart disease—do doctors test for it automatically for them?

Dr. Waqas Malick: Right now, it depends on the individual physician, and that doctor-patient relationship to discuss it. There's no official imposition that every patient must have it checked. So, it usually comes down to whether or not the patient wants to have it checked and to discuss it with their doctor, whether or not it's necessary.

I check in all of my patients, pretty much almost entirely, unless you come to me at a relatively advanced age with no history of heart disease, then I think that's probably not worth checking, because it's unlikely that we're going to find anything positive. But yeah, we recommend having it checked in everybody at least once, but that discussion can be individualized of whether or not it's necessary.

Host: Is it a blood test?

Dr. Waqas Malick: Yes. So, It can be checked with a traditional lipid panel. You get a blood test done with your annual physical. You can also get an Lp(a) checked at the same time.

Host: Who should be tested for Lp(a) and is it something lifestyle changes can improve?

Dr. Waqas Malick: So, the guidelines currently recommend that everyone should have it checked at least once. So, you go to your primary care doctor for your annual physical, you check it. You find that it's normal, you never have to check it again. If you go to your primary care doctor and you check and you find that it's high, you technically don't have to check it again either, because now you know it's high and it's high when it's above 125 and the risk increases linearly. Technically, it's high above 75. But we call 75 to 125 for right now gray zone as we still continue to do research and understand where the risk really starts to escalate.

If you know you have that risk factor, then from a primary prevention standpoint, we recommend the modification of other risk factors even more greatly. So, for example, get the LDL lower, exercise more, eat healthier, have more healthy fats to bring your inflammation levels down, to avoid diabetes or even pre-diabetes and insulin resistance, to avoid obesity. So, that's what we do from a primary prevention standpoint.

From a secondary prevention standpoint. So, let's say you're somebody that's already had disease and now you find out your Lp(a) is high, we recommend a few things. Number one, if your LDL is still uncontrolled, it should be lower. and there are new therapies on the market or they're not new. They've been around for a while, but now the guidelines recommend them as class one for patients with high Lp(a) with uncontrolled LDL, PCSK9 inhibitors.

Number two, your family members should all be screened for Lp(a), especially all first-degree relatives since it runs in families. So if your parents haven't had it ever checked and they're still alive, they should have it checked and your siblings and your kids. That way, we can get ahead of the risk early and make sure we're not missing any disease or preventing premature disease in your family members as well.

Host: If someone has elevated cholesterol or Lp(a), how do you personalize their risk assessment and treatment plan?

Dr. Waqas Malick: I think, number one, family history plays a large role for me. We know that when you look at the disease history, our coronary disease, history, risk, family history plays the biggest role, regardless of the cholesterol numbers, Lp(a), numbers, et cetera. If the LDL and the Lp(a) are both high, then that gives us something to target if we need to.

But first and foremost, no matter what lifestyle plays a big role. So, I always recommend nutritionally the five healthy fats, olive oil, nuts, avocados, seeds, particularly chia seeds and flax seeds and fish. And then, I recommend a high fiber diet, particularly high in green leafy vegetables, as well as whole grains and seeds as well, which is a double whammy with the chia seeds and flax seeds serving both as high fiber and high unsaturated fatty acids. And then, I recommend to usually avoid saturated fats or eat them in like moderation, you know, not too much.

If we don't control the risk well through there, we move to pharmaceutical management And we offer medications to help keep the numbers lower. But before we do that, we always risk stratify further with usually imaging. You want to make sure that if you're going to start therapy, if you're very reluctant, that there's a very good reason to do so. And imaging usually helps a lot.

And the way we do imaging, there's three types of tests that we can really do for premature screening, depending on what kind of access you have. The first is a coronary artery calcium score. This is a test you pay for out of pocket and detects any sort of premature calcified coronary plaque.

The second is a carotid artery Doppler. You can screen for plaque in the carotid arteries, which service the brain. And then, the third is a coronary CTA, which is where you get IV contrast and you can sometimes check for plaque. But usually, the indication for that is if you have chest pain, you want to make sure there's no blockages.

So really, the two tests we do for imaging perspective is calcium scores and carotid Dopplers. If you're found to have very high numbers with plaque, we recommend being very aggressive to avoid a cardiovascular event.

Host: Are triglycerides important? What role do they play?

Dr. Waqas Malick: So from a cardiovascular disease perspective, there's still a large gap in understanding triglycerides. So when we look at the history of triglyceride treatment, initially, we were treating patients with drugs called fibrates. And these drugs will lower triglycerides, but they did not have any impact on reducing heart attack, strokes, revascularization.

After that, we move over to like, you know, the fish oil supplementation and some of the fish oil supplementation trials did not really show any positive impact. But one did, which was a purified version of eicosapentaenoic acid called Vascepa. But really beyond that, we haven't really shown much impact on triglyceride outcomes.

More recently though, there have been new pharmaceuticals developed for patients who have very high triglycerides, and these are patients we call severe hypertriglyceridemia, usually more than 880, above a thousand. And the indication for them is actually different than what has been traditionally for considered triglycerides, which is when your lower triglycerides, like around 200, 300, 400, you're worried about cardiovascular disease risk because of the metabolic syndrome effect.

But as you get higher, you become more worried about pancreatitis risk, rather than coronary disease risk. And where the line really demarcates, we don't fully know yet. But it's a spectrum. And so, what you really worry about is pancreatitis because once you have one pancreatitis event and you have high triglycerides, your risk of a second pancreatitis event is very high. And pancreatitis itself, which is inflammation of the pancreas can be a very high morbidity and mortality occurrence. And so, we definitely want to avoid that. And so, there are new therapies available to reduce triglycerides in patients like those.

Host: For listeners who don't know their cholesterol, Lp(a) and/or triglycerides, what's the most important step they should take next?

Dr. Waqas Malick: I would first establish care with a primary care doctor and just get those tests regularly. Start with just a once a year, you know, annual visit. Our primary care doctors at Valley are excellent, and have been screening for Lp(a) as well as on the lipid panel, checking for markers for risk. And they'll also start this process of even imaging screening sometimes with calcium scores. For anybody who has more advanced risk or advanced disease, you know, we are happy to see them in our lipids and cardiometabolic disease program.

Host: In closing, is there anything else you'd like to add that maybe we didn't cover?

Dr. Waqas Malick: One thing I would say is just beware of misinformation out there. There's a lot of misinformation about cholesterol, especially in social media. And it's very important to understand that what people preach or say online may not apply to you as an individual. And so, it's very important to have these discussions established care with your primary care doctor or a cardiologist to discuss your individual risk profile, and to make sure you're on top of it. And there are a lot of lifestyle fads and diets that are promoted on social media that may not be beneficial for you. And so, make sure you are always doing things safely and in conjunction with advice from a medical professional.

Host: So true. Thank you so much for sharing your expertise today. This has been so informative. We really appreciate it.

Dr. Waqas Malick: Thank you for having me and a pleasure to be here.

Host: Of course. Again, that's Dr. Waqas Malick. We hope today's conversation has helped clear up some common myths about cholesterol and shed light on the hidden risk of lipoprotein or Lp(a), understanding your numbers, including the ones you may not routinely hear about, is an important step in preventing heart disease and making informed decisions about your health.

If you have questions about your cholesterol or want to know whether Lp(a) testing is right for you, don't wait. Talk to your doctor. For more information and resources, visit valley health.com/heart. And as always, be sure to subscribe. Share this episode and take good care.