Ask the Doctors February 2013 Issue

Ask The Doctors: February 2013

Q. I understand that my total cholesterol goal should be less than 200 mg/dL, but is there a lower limit that should be avoided? A relative had a total cholesterol level of 130 mg/dL and was told that it might be too low. Is that true?

A. The issue of low cholesterol is often described as a “chicken or the egg” problem.  Given what we know from many years of clinical studies, there is scant data to suggest that a low cholesterol level causes harm.  That being said, a very low cholesterol level can be the result of other health problems, including liver disease, cancer, and poor nutrition. Sometimes low cholesterol levels can found in patients with depression and anxiety, but it isn’t known whether the low cholesterol is the cause or the result of these states. When a patient like your relative is found to have a low cholesterol level, and they are not on cholesterol-lowering medication, the first question should be why it’s so low; not whether or not the low level is going to hurt them.  

The risk of strokes from bleeding into the brain (hemorrhagic strokes) may be somewhat increased for those with low cholesterol. However, in general it is clear that “lower is better” when it comes to cholesterol levels and the risk of heart attack, as well as the most common types of strokes: those from blockages in head and neck vessels (ischemic strokes). There are established guidelines to lower cholesterol below certain points, and the focus of attention is on LDL or “bad” cholesterol. For patients diagnosed with coronary artery disease (CAD) or ischemic stroke, as well as those with certain “risk equivalents” like diabetes and aortic aneurysm, the goal is to treat the LDL to less than 70 mg/dL. There is no level that is considered too low for treatment. However, once the level gets to 50 mg/dL or below, there is probably not much additional benefit. Also, doctors will often step back the dosage of statin drugs if their patients have elevations in liver or muscle enzymes, or if they are experiencing muscle pain or weakness.

Q. I know I should ask questions of my cardiologist and report new symptoms or side effects in between appointments, but my doctor is hard to reach. Are there guidelines about what questions or information can wait for an appointment and what should be reported immediately? And should I just have these conversations with the nurse if the doctor isn’t available, or a pharmacist if it’s about medications?

A. If you are concerned about any symptom you are having, it is important that you speak to either the nurse in the doctor’s office, or to a pharmacist (if you suspect an adverse drug effect) as soon as possible. It is difficult to know whether or not what you are experiencing is considered acceptable, and in general it is “better to be safe than sorry.” The questions which can wait until appointments would involve the timing and rationale for regular testing, and the need for medication changes based upon test results, but not when symptoms are involved.

A nurse may be able to answer many of your questions, or decide that what you’re concerned about does indeed need a consultation with your physician.

If you have tried more than once to contact your cardiologist’s office (sometimes persistence is needed!) and don’t feel your questions have been answered, then you should contact one of your other doctors – for example, your primary care physician (PCP). That way, at least you may get headed in the right direction in terms of having your issues addressed.

And never hesitate to seek emergency care if you suspect your symptoms may indicate a heart attack, stroke or some other serious problem, especially if you are at high risk for a cardiovascular event.