Prevention, Diagnosis and Treatment of Lipid Disorders
Q&A With Dr. Khalid Sheikh
ADVANCED LIPID MANAGEMENT
KHALID SHEIKH, MD, MBA, FACC, completed his undergraduate and medical studies at the University of Florida. Following his residency at the University of Colorado, he did his cardiology fellowship at Duke University. He was an Assistant Professor in Cardiology at Duke until 1991, when he entered private practice in Brevard County, Florida. He practices with Health First Cardiovascular Specialists; offices in Cocoa Beach, Merritt Island and Suntree/Viera. Dr. Sheikh is board certified in Cardiovascular Diseases, Echocardiography and is a Certified Lipid Specialist. His professional interests include preventative cardiology, cardiac imaging, invasive cardiology and clinical research. He is the Director of Cardiology at Cape Canaveral Hospital. He has been a principal investigator in over 100 national and international clinical research trials and has authored over 150 scientific articles, book chapters and reviews.
BREVARD COUNTY, FLORIDA – SpaceCoastMedicine.com welcomes Dr. Khalid Sheikh, Cardiologist and Certified Lipid Specialist (Lipidologist), to address the many questions related to the prevention, diagnosis and treatment of lipid disorders.
THE SPECTRUM OF cardiovascular diseases encompasses heart attacks, stroke, coronary arteriosclerosis, congestive heart failure, peripheral arterial disease and aortic arteriosclerosis.
These diseases are the leading causes of death for both men and women in the United States. Each year over 500,000 new heart attacks and over 500,000 new strokes occur, with nearly half of these individuals dying before they reach the hospital.
Arteriosclerosis is the underlying disorder in nearly all types of cardiovascular disease. This process involves the accumulation of fatty plaque inside blood vessels or arteries to cause injury to the blood vessels, weaken their interior lining and interfere with the blood flow through these arteries.
Of those patients who develop arteriosclerosis, over 90 percent have at least one risk factor such as high blood pressure, diabetes, smoking, family history, high cholesterol, obesity, unhealthy diets and physical inactivity.
As a result of a dramatic increase in the incidence of these risk factors in the general population, the rates of cardiovascular disease in the United States are soaring.
In 1991 only 20 percent of the U.S. population had more than two risk factors for arteriosclerosis; however, when last checked in 2003, this number exceeded 30 percent, and is likely even higher now.
The rates of most risk factors in the adult U.S. population in the last decade have significantly worsened as follows; hypertension increased from 33 to 37 percent, obesity increased from 28 to 36 percent, physical inactivity increased from 47 to 57 percent, unhealthy diets increased from 58 to 74 percent. Perhaps the most alarming trend was an increase in diabetes from 8 to 11 percent.
It is now projected that more than 1.5 million patients will be newly diagnosed with diabetes every year. It is only because of aggressive public health initiatives that cigarette use is the only risk factor that remained unchanged during the last decade, but still a substantial 26 percent of the U.S. adult population continues to smoke.
The mechanism through which all of these risk factors exert their harmful effects is through deposition of cholesterol and fat into the arterial wall. Thus, a major emphasis in preventing and treating arteriosclerosis is to not only control each individual risk factor, but also control cholesterol and lipid metabolism.
DIET AND LIFESTYLE changes are the cornerstone of cholesterol and triglyceride treatment. LDL cholesterol can be reduced by as much as 50 percent and triglycerides by as much as 80 percent with a proper diet.
The understanding of lipid metabolism and how to modify it to lower the risk of arteriosclerosis has become a major focus in medicine and public health. Our understanding of lipid metabolism has become much more sophisticated than simply measuring and treating cholesterol levels.
As a result, we have now entered the era of advanced lipid management. This area crosses specialty lines between cardiology, endocrinology, geriatrics, cardiac and vascular surgery as well as family and internal medicine.
The rapidly increasing incidence of cardiovascular diseases, risk factors and the resultant major public health epidemic has led to the development of a specialty dedicated to treating and preventing arteriosclerosis called lipidology.
SPACECOASTMEDICINE.COM: What are lipids and how is cholesterol related?
DR. SHEIKH: Lipids are a class of chemical compounds that include cholesterol and triglycerides. Lipids circulate in the bloodstream in combination with proteins in a molecular complex called lipoproteins. Cholesterol is a lipid molecule made by animals and humans that is used by the body to make cell walls, steroid hormones, vitamin D and bile. Some cholesterol is essential for normal body function but when it becomes elevated it can lead to hardening of the arteries (also known as arteriosclerosis), which over time can cause heart attacks and strokes.
SPACECOASTMEDICINE.COM: What is the difference between LDL and HDL cholesterol?
DR. SHEIKH: The body carries cholesterol in different ways. LDL (the “bad” cholesterol) is the cholesterol made in the liver that is carried to the artery walls leading to arteriosclerosis. HDL (the “good” cholesterol) is the cholesterol that is being removed from the artery wall and carried back to the liver to be excreted, a process known as reverse transport. Many experts believe an imbalance between LDL and HDL cholesterol is important in leading to cholesterol accumulation in the artery wall.
SPACECOASTMEDICINE.COM: Why should lipid disorders be treated?
DR. SHEIKH: High cholesterol and triglycerides are the main causes of heart attacks and strokes. Many medical studies have shown that treatments that lower cholesterol and triglycerides reduce a patient’s risk for heart attack and stroke by as much as 90 percent.
SPACECOASTMEDICINE.COM: What are the risk factors for heart disease?
DR. SHEIKH: The well-established risk factors for coronary artery disease include age, obesity, smoking, hypertension, high cholesterol and diabetes. You also may be at risk if heart disease runs in your family.
SPACECOASTMEDICINE.COM: How important are diet and lifestyle changes in treating lipid disorders?
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DR. SHEIKH: Diet and lifestyle changes will favorably affect cardiac risk factors. Blood pressure, diabetes and obesity will all improve through adopting a healthier lifestyle. Furthermore, diet and lifestyle changes are the cornerstone of cholesterol and triglyceride treatment. LDL cholesterol can be reduced by as much as 50 percent and triglycerides by as much as 80 percent with a proper diet. Increased physical activity and stopping smoking are the best way to raise HDL.
SPACECOASTMEDICINE.COM: What are the symptoms of high cholesterol?
DR. SHEIKH: High cholesterol does not make you feel sick. It is usually found during a routine blood test that measures cholesterol levels. You may first discover it when you are diagnosed with a condition that is caused in part by high cholesterol, such as coronary artery disease, stroke or peripheral arterial disease.
A small number of people with genetic lipid disorders such as familial hypercholesterolemia, may have other distinct symptoms such as deposits of excess cholesterol that collect in the skin. These cholesterol deposits can also cause bumps in the tendons of the hands or feet.
SPACECOASTMEDICINE.COM: When should I have my cholesterol tested?
DR. SHEIKH: Some doctors and health organizations recommend that everyone older than 20 be checked for high cholesterol. How often you should be checked depends on whether you have other health problems and your overall chance of heart disease.
Most experts agree that at a minimum, the following people should have their cholesterol checked:
- Anyone who has strong risk factors for heart disease
- People who have a family history of early arteriosclerosis
- Men ages 35 to 65
- Women ages 45 to 65
An adult who has coronary artery disease should have a cholesterol test at least once a year. An adult who is being treated for high cholesterol may need more frequent tests, depending on his or her cholesterol level and the type of treatment being used. Most adults who have diabetes should be tested at least once a year.
SPACECOASTMEDICINE.COM: What type of examination is used to detect cholesterol disorders?
DR. SHEIKH: A simple blood test will check to see if you have high cholesterol. A total cholesterol test measures whether your cholesterol is high or low. You can have this test done at any time, even if you recently had a meal or snack.
A lipoprotein analysis is also a blood test but is a more sophisticated examination that measures your LDL, HDL and triglycerides. It is called a fasting test because you are not supposed to eat for 9 to 12 hours before having your blood drawn.
Even more information can be obtained through an advanced lipid panel that measures the various types of lipid particles and lipoproteins in your bloodstream, as well as genetic markers that affect cholesterol metabolism. This type of testing is especially important if you are at high risk for, or have already developed arterisclerosis, are on lipid medications, or have a family history of lipid disorders or arteriosclerosis.
SPACECOASTMEDICINE.COM: When should I consider taking medication to improve lipids?
DR. SHEIKH: Medications to treat lipid disorders are usually prescribed only if diet and lifestyle changes are ineffective, or if lipid values are sufficiently abnormal that they pose a significant and imminent risk for the development of arteriosclerosis.
SPACECOASTMEDICINE.COM: What medication treatment options are there for lipid disorders?
DR. SHEIKH: There are a number of medications on the market now and they work in different ways. Some work in the stomach; some in the liver. Some prevent your body from making cholesterol; some prevent your body from absorbing it. Some medications are stored in the fat; some aren’t. The key is to find the right medication, or combinations of medications, that work for you.
SPACECOASTMEDICINE.COM: We hear a lot about “statins”—what exactly are they?
DR. SHEIKH: Statins are a class of drugs that work by blocking the most important step in the formation of cholesterol. The result is a reduction in cholesterol through removal of LDL (bad cholesterol) from the blood.
SPACECOASTMEDICINE.COM: Is there more to cholesterol management than prescribing a statin?
DR. SHEIKH: Yes, most certainly. Your doctor should know the way all the different drugs should be used separately, or in combination, to lower the bad cholesterol, raise the good cholesterol and lower triglycerides. In addition to medication, it is important to form a program around your particular situation, to ensure best outcomes.
SPACECOASTMEDICINE.COM: How do I know if my doctor is experienced in cholesterol management?
DR. SHEIKH: The simplest way is to ask informed questions. In general, preventive cardiologists, some cardiothoracic and vascular surgeons, and any doctor with some lipid management training, should have a good knowledge base in which to address difficult problems in cholesterol management. However, to be certain you are receiving the best care, you should visit a physician who is dedicated to cholesterol treatment and management.
SPACECOASTMEDICINE.COM: What is a lipidologist and when should I consider a consultation with one?
DR. SHEIKH: A lipidologist is a doctor who has received additional training in cholesterol management, cardiovascular risk assessment and intervention. In addition to a medical degree, a lipidologist has a written certificate attesting to the completion of this special training.
As this field is still very young, there are fewer than 400 certified lipidologists nationwide. The American Board of Clinical Lipidology, the group that oversees this certification curriculum, recognized its first graduating class in 2005.
For most people battling high cholesterol levels, a primary care physician will first suggest lifestyle changes. For most people, the National Cholesterol Education Program (NCEP) and American Heart Association recommend trying a three-month lifestyle change before starting any cholesterol medication.
If lifestyle changes are not enough, the NCEP then recommends beginning a LDL-lowering medication program under the guidance of a primary care physician. If this medication regimen has not effectively lowered cholesterol levels to a healthy level within 12 weeks, the group then advises seeing a lipidologist.
A cardiologist should be consulted if the primary care physician or patient has immediate concerns about heart disease, or if the patient has other risk factors, such as high blood pressure or diabetes.
Though certified lipidologists have been through specialized training for cholesterol management, the same medical tests and treatments they recommend can also be prescribed by a primary care physician or other internal medicine specialist.
In fact, the National Heart, Lung and Blood Institute recommends that a lipidologist work in conjunction with a patient’s primary care physician, registered dietician, nurse and pharmacist.
This will allow each team member to be aware of all recommendations provided to the patient. The patient can also encourage communication between team members by keeping a cholesterol management journal.
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PHYSICIANS, and physician’s wives, took part in the Brevard County Medical Society’s “Women of Medicine with Heart” fashion show to raise funds to provide local high school athletes with physician-conducted physical exams that include EKGs.
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