High Cholesterol and Peripheral Artery Disease

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I know that high cholesterol is bad for me. But my doctor says that my triglycerides are elevated. Do I need to worry?

Triglycerides (TGs) are a type of lipid stored in fat cells and used to supply energy to the body. Like cholesterol, they are transported in complexes called lipoproteins, and high levels are bad. Hypertriglyceridemia is detected by a simple blood test. Very high levels (>500 to 1000 mg/dL) have been associated with pancreatitis, but even modest elevations are also linked to heart and vascular disease. Levels above 150 mg/dL are considered elevated. Even if the bad cholesterol (LDL) is well treated, elevation in TGs, especially if associated with low HDL cholesterol, identifies a higher risk for future vascular events.

It is important to identify and eliminate or treat secondary causes. Medical conditions (such as an underactive thyroid, diabetes, metabolic syndrome, liver or kidney disease) or certain medications (such as antiviral drugs, birth control pills) may raise TGs. There may also be genetic causes. More commonly it’s due to or worsened by weight gain, being sedentary and high intake of fat and carbohydrates. Initial treatment focuses on diet, weight loss (of 5 and 10 percent) and exercise, the same lifestyle choices that promote overall health. Decreased intake of saturated fat but also of alcohol, sugar and white flour carbohydrates is important. Consultation with a nutritionist can go a long way in guiding dietary changes. A regular aerobic exercise program helps, even if it’s walking for 30 minutes five times a week.

When TGs are elevated, medications such as statins, niacin, high-dose omega 3 fish oil or fibrates (e.g. TriCor, Lopid) may be prescribed. How much impact this has on preventing future heart attacks or strokes, particularly in patients with mild elevations, remains unclear. You can help yourself by instituting healthy diet and lifestyle choices. Your doctor can help decide if there is a role for medications.

I have been told by my physician that I have peripheral artery disease. I have very minimal symptoms. Why does she want to start medicines used in heart disease?

Peripheral artery disease or PAD is a condition in which narrowed blood vessels reduce blood flow to the limbs, commonly the legs. It occurs in 12 to 14 percent of the population and increases with age. Symptoms known as intermittent claudication include pain, cramping or fatigue in the thighs or calves provoked by walking and resolved with rest and are sometimes mistakenly attributed to back or spine disease. Cold or discolored extremities or ulcers may also be reported in severe cases. However up to 50 percent of those with PAD have no symptoms. The same risk factors responsible for plaque buildup and atherosclerosis in heart and brain vascular disease are those for PAD. Therefore, it is not surprising that people with PAD have a greater risk of heart attack and stroke. In fact, if you have PAD the risk is increased up to six-fold. Treatment is two-fold: Reduce symptoms and prevent other vascular disease. Symptoms may be controlled with medications such as cilostazol (Pletal) and lifestyle changes. Exercise programs designed to repetitively exercise up to symptom development, with rest periods in between, have been shown to increase walking time and distance. Stents and bypass surgery are considered for refractory symptoms or threat of limb loss. Clot-reducing therapies such as aspirin or clopidogrel (Plavix), control of blood pressure, statin drugs to reduce cholesterol and healthy lifestyle approaches, especially smoking cessation, target prevention of other cardiovascular diseases. To improve not only quality of life but also to prevent heart attack, stroke and limb loss, treatment of PAD often requires the combined efforts of your primary care physician along with specialists in vascular medicine, vascular surgery and preventive cardiology.

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