Non-HDL Cholesterol and The New Cholesterol Guidelines

If non-HDL cholesterol was viewed as a key predictor of cardiac disease risk (on par with apoB or LDL particle testing), why was it abandoned in the new November 2013 cholesterol guidelines?

This is something I’ve been thinking about for a while.  Because for those with diabetes or high triglycerides, it was considered vital to know non-HDL cholesterol. (Do You Know Your Non-HDL Cholesterol? explains why, and how easy it is to calculate from just a standard cholesterol lipid blood test.)

Let me start with a brief, very non-technical definition (for more technical info click blog post link above).  Non-HDL cholesterol is a measure that estimates the level of ALL the bad types of cholesterol in the blood.  Think of it this way: subtracting HDL (good) from total cholesterol yield the non-HDL cholesterol number, which is a measure of all the ‘bad’ cholesterol in the blood. That means it’s a measure of all LDL: the ‘regular-old’ LDL (bad) cholesterol number, which is the number that appears on a report, plus all the other carriers of ‘bad’ cholesterol, such as VLDL (very low density lipoprotein) and IDL (intermediate density lipoprotein) – which are not included in the regular-old LDL cholesterol measurement listed on a cholesterol lipid panel report.

Though it was not as widely known/used by doctors as regular-old LDL cholesterol, it’s true that non-HDL-C was  proven to be a better indicator of cardiac disease risk than just LDL cholesterol.

Indeed, as explained in the Mayo Clinic’s Cardiovascular Risk Assessment Beyond LDL Cholesterol: Non-HDL Cholesterol, LDL Particle Number, and Apolipoprotein B, non-HDL-C  is a better measure of cardiac risk than LDL cholesterol:

“Several known limitations make LDL-C a less accurate marker of cardiovascular risk than either non-high-density lipoprotein cholesterol (non-HDL-C), LDL particle number, or apolipoprotein B (apoB).”

“Advocacy for non-HDL-C began following widespread recognition of its superiority over LDL-C as a measurement of vascular event risk and demonstrated equivalency to apoB or LDL particle number in some clinical trials.”

If it was widely accepted in the medical community that non-HDL-C was a better predictor than LDL alone – and indeed, a good proxy for apoB or LDL particle testing, why were BOTH the LDL and the non-HDL-C measures abandoned in the new guidelines?

The answer seems to be that there is no rationale for setting a specific number target for either LDL or non-HDL-C.

I get it for LDL cholesterol. LDL was used as a key measure to determine whether someone should take a statin, even though there was no real rationale for a specific LDL number as a goal (which is crazy but is basically what’s been the case for many years now). Thus, the committee recommended a new risk assessment measure that was based on research – and eliminated the ‘random’ LDL goal.

Makes sense.

And yet.

If it is/was widely accepted and studies have shown that apoB and LDL particle size are predictive of cardiac risk, and non-HDL-C is an easy, cost-effective way to approximately measure apoB and LDL particle size (because non-HDL is calculated from a typical cholesterol test – not a whole new test like apoB) then it seems to me that knowing your Non-HDL-C is a good idea.

But hey, I’m no doctor. (And I don’t even pretend to play one on TV). So I could be wrong.

That said, I’m concerned. The new guidelines say I’m (suddenly, now) very low risk for cardiac disease. But my non-HDL cholesterol is significantly higher than the old “goal” of 130 for those with high triglycerides.

And I get that the 130 figure is not, in and of itself, a meaningful target.

I do.  Truly.

But it seems clear since my non-HDL-C is “high” compared with ‘normal’ or a lot of other people, that this might indicate a potential problem. And thus warrant action.  Not treatment – I get that it doesn’t make sense to recommend a statin based on a goal number that’s not grounded in research.

But to me, it seems that if non-HDL-C is greater than 130 then further testing could be indicated.

Again, I’m no doctor.

But I think it’s important to ASK about this.  Perhaps the fact that my non-HDL is high indicates the need apoB and/or particle size testing – or one or several of the tests the AHA now indicates for those who might be at risk: see New Cholesterol Guidelines – An App For That.

Good thing I’m due for my annual checkup soon.  I will ask my doctor about these tests. AGAIN.

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New Cholesterol Guidelines – An App For That

The American Heart Association and the America College of Cardiology released completely new, totally different guidelines for the treatment of high blood cholesterol back in November 2013.

As explained in my post, The NEW Guidelines For Cholesterol-Lowering Statin Meds, in broad strokes the new guidelines state that if you are in one of the following four groups you have elevated heart disease risk and should take statins:

  1. those who already have cardiovascular disease
  2. anyone with LDL (bad) cholesterol of 190 mg/dL or higher
  3. anyone between 40 and 75 years of age who has Type 2 diabetes
  4. people between 40 and 75 who have an estimated 10-year risk of cardiovascular disease of 7.5 percent or higher.

To determine your personal 10-year risk of cardiac disease, the new guidelines included an online calculator * … and now that a few months have passed, there’s even AN APP FOR THAT (links to the app are on the online calculator webpage – or search ‘ASCVD Risk” in iTunes store). I downloaded the app for my iPhone and it’s quite handy as it saves your data and also provides articles about key topics like ‘diet and physical activity recommendations,’ and ‘common cardiovascular terms,’ and the like – right in the app.
* NOTE – if the link does not work, check for an updated link on my RESOURCES page.

One of the more interesting topics I found inside the app (in the Patients’ Blood Cholesterol Management Recommendations tab) discussed additional blood tests. After reviewing with your doctor your ‘lifetime risk estimate’ based on the inputs in the calculator/app, the article stated there were three additional tests your doctor may want to order:  Coronary Artery Calcium (CAC), High-Sensitivity C-Reactive Protein (CRP) and Ankle-Branchial Index (ABI).

The Coronary Artery Calcium test was one my doctor had talked with me about a few years ago. She asked me to find out whether anyone in my family (all of whom take a statin to manage high cholesterol) had had a Coronary Artery Calcium test done, and if so, what the results were. I failed at that. Apparently, I need to email all my cousins and aunts and uncles.  Today.

As I wrote about in Cholesterol Tests Your Doctor Hasn’t Told You About, the C-Reactive Protein test is a test (along with apo-B) that I would really like done to truly understand my cardiac risk. CRP is a measure of inflammation in the body and high levels have been associated with heart disease.  But my doctor declined to order either test for me back a year or two ago – said with my just-over-220 total cholesterol levels, I didn’t need these tests.

The Ankle-Branchial Index I’ve never heard of before. According to the ASCVD Risk app, ABI measures “the ratio of the blood pressure in the ankle compared to blood pressure in the arm, which can predict peripheral artery disease (PAD).”

So I will have to ask my doctor again about Coronary Artery Calcium, CRP, apo-B and ABI testing. I feel sure she won’t agree to this testing because my newly calculated lifetime risk is far below the 7.5% risk that indicates statin medication is needed.

That said, these tests are at least mentioned within the new guidelines, while others, like Non-HDL cholesterol are now no longer viewed as vital to determining cardiac disease risk and treatment plans. So even though my risk is low under the new guidelines and I am no longer in the group that should be taking statins, I want to ask about whether these tests might provide further insight into cardiac risk.

If you haven’t read about the new guidelines or found the new online calculator intimidating, download the new app.* Knowing your cardiac risk before you talk to your doctor will give you more confidence to ask questions about your risk of cardiac disease at your next appointment.

* You can’t use the calculator/app if you already have cardiac disease or take statins. If that’s you, best bet is to talk with your doctor about what the new guidelines mean for you and/or if a change in your statin medication is warranted.

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Baked Char or Shrimp Scampi with Spinach and Lemon

Recently, we had a bunch of family visiting with a wide range of palette preferences (meaning some would eat fish and some would not). My mom and I decided to make some chicken thighs in the crock pot for those who might not like fish, and I headed off to my favorite fish wholesaler, Pagano’s, to buy enough fish to feed 10-12.

At Pagano’s I decided to buy about 2 pounds of my favorite (and healthy) fish, Arctic char, and another 2 pounds of salmon (which I do not care for) and conduct a very informal taste-off. I prepared both the same way: first I generously salted each fillet, then sprinkled on some fresh pepper, slathered on Extra Virgin Olive Oil, then sprinkled with dried oregano, thyme and rosemary (because I forgot to buy fresh herbs).  Atop parchment paper on cookie sheets, I baked the 2 fillets at 450 degrees for about 12-15 minutes (note: if one end is thin and the other thick, tuck the thin end under or it will over-cook).

Baking a thick fish fillet like char or salmon this way is a snap. Preparation takes all of 1 minute and the result is delicious every single time. Everyone at our family get together – even the kids – liked it.  And folks were evenly split as well between the char and salmon. Which made me smile because prior to this, I was the only Arctic char fan – mostly because I was the only one who ever heard of it.

There was one big problem. The taste-off totally backfired on me, since my husband declared he far preferred the salmon (which again, I do not care for) to my favorite fish, Arctic char.

Sigh. So now when I bake fish – which is a go-to weeknight dish for me – I will have to buy and bake salmon AND char. Or pretend I forgot my husband preferred salmon.

Guess which I’m doing. (My poor husband.  And he’s such a nice guy, too.)

OK, so back to cooking fish.  The taste-off was in my mind the following week when I found myself at Pagano’s again. This time, I was cooking for just my husband and me – and I got the bright idea to buy not only the char and salmon (it’s too soon to play the ‘I forgot’ card!) but also some fresh shrimp so I could cook dinner at home 2 nights in a row.

Gasp.

Hasn’t happened in weeks.

But I did it.  I made the char/salmon on Tuesday night last week, and on Wednesday, I made a Shrimp Scampi with a dozen gorgeous fresh shrimp that William at Pagano’s kindly deveined and shelled for me.

The scampi recipe is a bit more complex. Oh, who am I kidding. The fish takes all of 1 minute to prepare while the scampi (as long as someone else deveins it) takes, oh, about 5 minutes.

So, pretty easy.  And yet a totally different flavor profile – and served over pasta instead of quinoa or rice – so it’s a nice alternative to a fillet.

I made my scampi with spinach but if you don’t care for spinach you could use parsley instead. The recipe I included below is a quick, easy, and pretty basic-tasting dish – it’s quite good, but not wildly flavorful (great if you are looking to please a group that includes kids). Personally, it ended up a bit too bland for us, so next time I make it, I’ll up the red pepper flakes and add a can of anchovies to the hot oil before cooking the shrimp: the anchovies melt in olive oil (literally, not kidding!) and impart a nice, deep flavor that does not taste like anchovies!

So if you are looking for a quick, healthy weeknight seafood dish that is neither overly spiced nor spicy, try either a baked fillet or a shrimp scampi. Recipes abound online, but my go-to simple fillet preparation is to just toss a nice thick salmon or Arctic char fillet that’s been salted, peppered, olive-oiled and dusted with a few herbs on a cookie sheet covered with parchment paper, and bake at 450 degrees for 12-15 minutes.

Or if you’re more in the mood for a pasta dish, try my recipe for: Shrimp Scampi with Spinach and Lemon. I’ve added both recipes to my Lo-Co Recipes page, for future reference.

And let me know if you try the anchovy trick – or have other ideas to up the punch of this shrimp scampi!

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