You probably know that fried chicken, a doughnut or a loaded double cheeseburger are not the best foods to put in your body. Why? Because foods like these are packed with unhealthy fats and lack many of the important nutrients for heart health. The good news is that a healthy diet can also taste great!

High cholesterol can be prevented and treated. Studies show that keeping LDL cholesterol low not only can prevent someone from developing clogged or narrowed arteries in the first place (primary prevention), but doing so also helps reduce the chance of a heart attack, stroke or related death among people who already have heart disease (secondary prevention).

The opposite is true, too: Those with high levels of high-density lipoprotein (HDL) – the “good” cholesterol – tend to have cleaner arteries and a lower chance of heart attack and stroke. That’s because HDL acts like a scavenger, helping to find harmful cholesterol and remove it from your arteries.

The challenge is that there are often no signs or red flags of having too much bad cholesterol until it starts to affect your arteries. For this reason, it’s important to know your cholesterol numbers and your related risk for developing heart disease, or having a heart attack or stroke.

Keeping LDL-cholesterol levels low is an essential part of staying heart healthy. Adopting a healthy diet, getting regular exercise, keeping weight well managed and, in some cases, taking medications, can go a long way to help.

Patient Voices: Managing High Cholesterol

Lower your LDL, or “bad” cholesterol, to protect your heart.

If you have high LDL cholesterol, you may feel fine. But over time, high levels of LDL cholesterol in your blood can build up and narrow or block blood vessels and arteries, which can trigger a heart attack or stroke. So taking steps to lower your LDL cholesterol is not simply about the number. It’s about lowering the chance of a first or future heart attack or stroke.

Tens of millions of Americans take a statin – widely considered the “gold standard” for treating high cholesterol along with heart-healthy choices like eating right and getting regular exercise.

Beyond helping to lower cholesterol, statins can also help prevent heart attacks and stroke – two leading causes of disability and death.

Yet, even though statins are one of the most prescribed medications, they are often misunderstood. Our experts help clear up some common misperceptions about their use.

WHAT YOU THINK OR MIGHT HAVE READ	WHAT RESEARCH AND CLINICAL EXPERIENCE TELL US ABOUT TAKING A STATIN
I feel great, so why would I need a statin?	Unlike taking an antibiotic to clear an infection that’s had you laid up in bed or a medication to ease a throbbing headache, you won’t “feel” the benefits of a statin. But that doesn’t mean it’s not working as it should. Most statins can cut cholesterol levels by half, But remember, while statins treat cholesterol, it’s really about treating your risk of having a heart attack or stroke.
I’ve heard statins often cause muscles pain and weakness. I worry that taking one will limit what I can do.	Most people taking a statin – 9 out of 10 – do NOT report muscle aches or weakness. Even among those who do, it is usually mild and can be managed.The trick is that aches and pains are quite common among the age group of people who stand to benefit from statins. There are many other potential causes including exercise, overexertion, sitting for too long, low vitamin D levels, thyroid problems, and arthritis to name a few. Statins tend to affect the large muscles of the legs and arms, not the joints. So experts say if your knee, hip or shoulder bother you, it’s unlikely related to the statin. The good news is that even if you do develop muscle symptoms thought to be related to your statin, there are others you can try.Bottom line: If you’re worried about it, ask your health care team to take a careful history of your aches and pains before you start on a statin. If you are already taking one and begin to have any muscle symptoms, your health care team can take steps to evaluate and manage them. Many times, it’s as easy as changing other medicines or boosting your vitamin D level.
I’ve heard cholesterol is good for my body.	While it’s true that we need some cholesterol for normal cell and body function, too much “bad” cholesterol can spell trouble. Over time, it can lead to a dangerous buildup of fat and plaque within the walls of your arteries. If this plaque breaks free or blocks the normal flow of blood, it can cause a heart attack or stroke.Bottom line: Taking a statin – if your health team recommends one – along with exercise, and a healthy diet, is one of the best ways to treat high cholesterol and manage your risk for cardiovascular disease, heart attack or stroke.
I don’t want to take anything that’s going to affect my memory or ability to think clearly.	There is no clear evidence that statins cause memory loss or problems with thinking. While the Food and Drug Administration added a safety alert label to statins in 2012, other medical experts including the Statin Safety Task Force have carefully looked at the research to conclude the evidence is weak if not nonexistent, even among people with Alzheimer’s disease.Among those who have developed memory loss or confusion while taking statins, these side effects reverse once you stop taking the medication.On the flip side, recent data suggest that statins may actually help ward off dementia. That’s because one of the potential causes of memory loss and altered thinking is dementia due to not enough blood flow to the brain, which statins can help with.Bottom line: Memory problems from statins seem to be unlikely and, in most cases, it is doubtful that statins are the cause. The same process that affects the arteries that supply the heart also can affect the arteries of the brain (called atherosclerosis); this is also a common form of dementia (vascular dementia). Talk with your health care team if you have concerns.
I’ve heard statins cause diabetes, and I know diabetes comes with a host of health concerns, including potential heart disease.	There is a small, potential risk of developing type 2 diabetes as a result of taking a statin. However, experts say this is most often among people who likely would have developed diabetes anyway. For example, they already had borderline blood glucose levels (those nearing diabetes, but not quite) and other risk factors, such as being overweight or being insulin resistant. So while they might develop diabetes a little sooner – data show about one month earlier than they would have off the statin – the benefit of being on a statin becomes even more important because once you have diabetes, you’re much more likely to develop cardiovascular disease.Bottom line: If you are at a healthy weight and don’t have other risk factors, it is very unlikely that you would develop diabetes from taking a statin.
Statins damage the liver.	While early research showed a link between statins and liver damage, we now know it is rare. In fact, the FDA no longer recommends routine liver tests after starting statin therapy unless you begin to have signs and symptoms of liver damage. These would include: unusual fatigue, loss of appetite, pain in your upper abdomen, dark-colored urine, or yellowing of your skin or eyes.Your clinician may order a blood test to check your liver before starting you on a statin just to make sure your liver is healthy.Bottom line: Statins are unlikely to hurt you liver. The benefit of preventing a stroke or heart attack far outweighs the small chance of any liver problems. If you’ve had liver problems or have hepatitis, be sure to tell your clinician. In many cases, you can still take a statin, but your liver levels will need to be checked.

eyond Statins

What You Need to Know About Other LDL Cholesterol-Lowering Treatments

What are Non-Statin Therapies?

Statins don’t work for everyone. In some cases, a statin by itself won’t lower your low-density lipoprotein (LDL) cholesterol or atherosclerotic cardiovascular disease (ASCVD) risk enough. In other cases, someone might not be able to take a statin.

When this happens, other medications – called non-statin therapies – offer more treatment options. Often, a non-statin will be added to a statin.

Non-Statin Therapies for Lowering LDL

Non-statin treatment	How it lowers LDL cholesterol	How it’s taken	Side effects to be aware of *	Added ASVCD risk reduction
Ezetimibe	Works by blocking the body’s ability to absorb cholesterol in the gut	By mouth, usually once daily	Diarrhea, stomach pain, muscle or joint pain, runny or stuffy nose, feeling tired	In some patients, adding ezetimibe to statin therapy lowered cardiovascular events.
Bempedoic acid	Partly blocks the production of cholesterol in the liver	By mouth, once daily	Muscle spasms, back pain, pain in hands or feet	A study is being done to determine if bempedoic acid lowers cardiovascular risk in patients at risk for cardiovascular disease events who cannot take statin therapy.
PCSK9 inhibitors	Works by helping the body get rid of LDL cholesterol from the blood by blocking a protein in the liver (called proprotein convertase subtilisin kexin 9, or PCSK9)	Given under the skin by injection, 1-2 times a month	Skin reactions at the site of injection, allergic reactions, headache, influenza	In some patients, adding a PCSK9 inhibitor to statin therapy (with or without ezetimibe) lowered cardiovascular events.

_{* These are just some of the possible side effects. Always be sure to read the package insert that comes with your medication for a full list of side effects and other instructions.}

Other medications, including fibrates and omega-3 fatty acids (by prescription) may be recommended for overall dyslipidemia—an abnormal level of one or more kinds of lipid (fat) in your blood.

When are Non-Statin Therapies Recommended?

Non-statin therapies may be recommended if:

• Your blood cholesterol remains high or you don’t see the drop in LDL cholesterol expected, despite being on the right dose of a statin.
• Your health care team wants to lower your ASCVD risk more—helping to prevent a stroke or heart attack.
• You can’t take a statin for some reason, either due to side effects or a certain drug-drug interaction.
• You have familial hypercholesterolemia, or FH, a disorder passed down in families that results in very high levels of LDL cholesterol and cardiovascular disease at early ages.
• Other factors, such as your preference for treatment and cost, may also come into play.

How Much Might It Lower My Cholesterol?

It depends. Studies suggest ezetimibe and PCSK9 inhibitors can lower cholesterol and, in turn, cardiovascular disease risk. Often, a non-statin is taken with a statin for additive effect, meaning both medications work together to give you the maximum benefit.

Treatment	Can Lower LDL Cholesterol
Statins (high intensity)	More than 50%
Ezetimibe	Further lower by up to 25%
Bempedoic acid	Further lower by up to 25%
PCSK9 Inhibitors	Further lower by 60% among people taking a statin
Bile Acid Binding Resins (Sequestrants)	15%-25%

PCSK9 inhibitors are the newest treatment and have been shown to significantly lower LDL. The effect is even greater when combined with a statin in the highest amount (dose) possible.

Your Personal Risk of Heart Attack or Stroke

Your health care team may have already talked with you about how a risk calculator can be used to find your risk of developing ASCVD or having a heart attack or stroke. This calculator factors in things like:

• Age
• Sex
• Race
• Cholesterol
• Systolic blood pressure (the top number)
• If you smoke
• If you have diabetes

Your care team may also consider other factors that play a role or affect your risk. 

Because your risk can change over time, it’s important to keep talking with your health care team about what steps you can take to stay healthy as you age.

Keep in mind that making lifestyle changes – in addition to taking a statin or other medication – can help protect your heart and improve your overall health.

How Do I Decide the Best Next Step for Me?

There are a number of things you might want to consider and talk with your health care team about as you think about whether to add a non-statin therapy.

• First, are you on the most potent and highest amount (dose) of such statin you can take already?
• How well have you managed to make lifestyle changes, including eating heart healthier and getting regular physical activity?
• What is your personal risk of ASCVD, and how much more would a non-statin lower that risk beyond what has been achieved on a statin alone?
• Possible drug-drug interactions, especially if you have other health issues.
• What you prefer for treatment once you know or understand your risk.

How Often Do I Need My Cholesterol Checked?

It is important to have your cholesterol levels tested again. This is often done:

• At the start of treatment
• 4-12 weeks after starting or changing a statin or other LDL cholesterol-lowering therapy
• At set times after that based on your care team’s advice (usually 3-12 months)

What Should I Ask My Health Care Team?

As with starting any medication, talk with your health care team, share concerns and ask questions. For example, you might ask:

• Why are you recommending this treatment?
• How much more will it lower my cholesterol and my risk for a heart attack or stroke?
• How will we know if the medication is working?
• Are there certain side effects I should watch for? What should I do if I notice any?
• How often do I need to have my cholesterol checked?
• What else can I be doing to lower my chances of having a stroke or heart attack?
• Will my insurance cover it, especially the more costly, newer drugs?

What are statins? Statins are medications that are used to help lower cholesterol levels. But statins don’t just help keep cholesterol levels in check, they also protect your heart.

Studies show that, for many people, these medications can:

• Protect against the stiffening or hardening of the arteries (called atherosclerosis) 
• Prevent heart attacks and strokes
• Save lives

What is Cholesterol?

Cholesterol is a waxy, fat-like substance that travels through the blood. Too much can increase your risk for heart attack or stroke.

Our bodies make and need some cholesterol to work. But too much can hurt your heart health. Very high levels can promote the buildup of cholesterol, fat and other substances – also called plaque – in the walls of arteries. This buildup can block blood flow.

Unlike a headache, chest cold or stomach upset, high cholesterol usually has no symptoms. But it’s a big red flag when it comes to the chance that someone will develop heart or blood vessel problems.

How Do Statins Work?

Statins lower cholesterol in the blood by reducing the liver’s ability to make cholesterol. This allows the liver to accept more cholesterol from the blood, which in turn drives down cholesterol levels. They can drive down low-density lipoprotein (LDL) cholesterol levels – the “bad” cholesterol – by more than 50%.

Statins also help prevent heart attacks and strokes by keeping plaques from breaking apart and forming clots that can move to the heart or brain. In addition, they can lower triglycerides and boost high-density lipoprotein (HDL) cholesterol – known as the “good” cholesterol.

Statins work best when combined with a heart-healthy eating plan, regular exercise and other healthy habits.

Who Should Take Them?

Statins are often recommended to help prevent a first heart attack or stroke (called primary prevention).

They are also used to reduce the risk of having a repeat heart attack or stroke  in someone who has already had one (called secondary prevention).In general, you should consider being on a statin if you: *

• Know you have heart disease or have a history of stroke, heart attack, peripheral vascular disease or chest pain, also called angina (this is to prevent further problems – called secondary prevention)
• Have high cholesterol (LDL of 190 mg/dL or higher) or know you have Familial Hypercholesterolemia (FH)
• Are between 40 and 75 years of age and also have diabetes
• Are between 40 and 75 years of age and your clinician estimates how likely you are to have a heart attack or stroke or die from one in the next 10 years (called your 10-year risk score), and your risk is high enough to benefit from being on one.

If you or a loved one is over 75 years of age and have never been on a statin, the benefit of starting one is unclear. Talk with your health care team and decide what’s best.

Concerns About Statins

Despite recommendations, many people are worried about taking a statin, most often due to fears of side effects they have read or heard about. But most people who take a statin do not have side effects. 

As with starting any medication, it is important to talk with your health care team, share concerns, and ask questions. For example:

• What are my risk factors? What is my calculated risk for a heart attack or stroke in the next 10 years?
• How will I benefit from taking a statin?
• How will we know if it’s working?
• Are there specific side effects I should watch for? Whom should I call if I notice them or have other concerns? When should I call?
• What else can I be doing to lower my chances of having a stroke or heart attack?

Your Personal Risk of Heart Attack or Stroke

Remember: If your health care team suggests that you take a statin, it’s all to help lower the chances that you will have a heart attack or stroke caused by atherosclerotic cardiovascular disease (ASCVD).

ASCVD develops because of a buildup of sticky, cholesterol-rich plaque. Over time, this plaque can build up and narrow the arteries.

Your care team may have already talked with you about how a risk calculator can be used to find your risk of developing ASCVD or having a heart attack or stroke. This calculator factors in things like:

• Your age
• Sex
• Race
• Cholesterol
• Systolic blood pressure (the top number)
• If you smoke
• If you have diabetes

Your care team may also consider other factors that play a role or affect your risk. Because your risk can change over time, it’s important to keep talking with your care team about what steps you can take to stay healthy as you age.

Keep in mind that making lifestyle changes – in addition to taking a statin or other medication – can help protect your heart and improve your overall health.

How to Take Statins Safely

• Know why your health care team recommended a statin. If you have questions, ask.
• Share any concerns. Be open about any concerns that might get in the way of you actually filling the prescription or taking it the right way. For example, concerns about:
  • Taking a daily medication (you might be unsure if this is your first)
  • Adding yet another medication to the others you already take
  • Possible side effects you’ve heard or read about
  • Costs
• Report any side effects. Side effects are uncommon, but if you do have any, your health care team can try a new statin or change the dose (amount) you are taking. There are a lot of choices for you and your health care team. In some cases, your clinician may want to run other tests to find out if certain symptoms have other causes. For example, they might check your vitamin D or thyroid levels.
• Keep follow-up health visits. Most often, your health care team will start you on a high-intensity statin. At certain points in time, and especially a few weeks after starting one, they will want to check your blood work again, including your cholesterol levels to find out how the statin is working.
• Never stop taking your statin (or any prescription medicine) without talking with your health care team first.
• Ask if you should stay away from certain medications or foods. Certain drinks, foods and medications may change the way your statin – or other medications – work. For example, grapefruit juice can make some statins more potent and interacts with many other medications. Try not to drink grapefruit juice if you are taking a statin.
• Talk with your health care team if you are or plan to become pregnant.
• Update your medical history. Anytime you start a new therapy like a statin, it’s a good idea to tell your other health care team.

Statin ABCs

Assess and know your risk.

• Get your blood cholesterol levels checked
• Review with your health care team the other factors that raise your risk for heart attack and stroke

Begin treatment if you’re found to be at high risk for heart attack or stroke or already had either.

• You may not “feel” better taking a statin; that’s because it is to prevent problems
• Don’t stop taking a statin without talking with your health care team

Come back for repeat testing.

• After you’ve been on a statin for a few weeks (usually 6-8), blood tests can help find out how well it is working
• Treatment can be changed, as needed

What if Statins Don’t Work for Me?

Not all statins are the same. If you have a side effect with one or even more than one of the available statins, you still may be OK to take a lower amount (dose) of statin, a different statin or a (non-daily) longer-acting statin.

If statins aren’t enough to lower your ASCVD risk or you can’t take them for some reason, your health care team may recommend non-statin therapies.

These might include ezetimibe, which blocks cholesterol from being absorbed in the intestine, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors or bempedoic acid.

The end goal in bringing down your LDL-cholesterol is to lower the chance of a first or future heart attack or stroke due to blockages in your arteries.

Your treatment plan to lower your cholesterol numbers will be based on your overall risk for cardiovascular disease. For example, a standard risk assessment would note whether you already have atherosclerosis or have a high chance of developing it. Treatments will also depend on:

• Your cholesterol levels
• Other conditions you may have
• Treatments tried before (if applicable)
• Personal choice 

Trying to lower LDL levels often can be helped by making healthier lifestyle choices. In fact, the choices we make every day can affect our cholesterol. 

Here are four things that can make a difference:

1. Revamp the way you eat by following a heart-healthy plan such as the Mediterranean or DASH diets (these are less “diets” than ways to eat healthy)
2. Exercise regularly 
3. Stay at a healthy weight and lose any extra pounds
4. Don’t smoke, and stay away from secondhand smoke 

Many people with elevated LDL cholesterol, particular if it is an inherited condition, also need to take medication. 

Lifestyle Changes

Adopting a heart-healthy diet and getting regular physical activity are the most important steps you can take to prevent or control cholesterol problems and heart disease. It’s also important to maintain a healthy weight, don’t use tobacco, and manage stress.

Here are some tips about being active and eating better: 

• Get physical. Aim to get at least 30 minutes of (moderate-intensity) activity five times a week. Activities might include a brisk walk, jogging, riding a bike, swimming – even gardening or heavy housework. Even 10-minute bursts of activity three times during the day is helpful. Consider wearing a device that tracks the number of steps you take so that you know your starting point.
• Take time to read and understand food labels, and look for the amount of saturated fats, trans fats (hydrogenated or partially hydrogenated oils) and sugar content.
• Try to stay away from full-fat dairy products, processed foods, and foods high in salt (sodium) and preservatives.
• Eat healthier fats. Instead of butter or margarine, use olive oil or avocados. But try to stay away from fat that becomes solid when left on the counter. Nuts, fish, certain oils (olive, canola and peanut oils) and other foods rich in omega-3 fatty acids are also good choices.
• Try to include up to 30 grams of fiber in your diet each day. Eat a variety of foods, including berries, legumes, whole grains, green leafy vegetables and many others.
• Consider keeping a food diary so you can see what you are eating and what food habits you might need to change.
• Ask about seeing a dietitian or nutritionist who can help you plan meals and suggest ways to lower LDL or triglycerides, improve your sugar levels and boost your energy.
• As with any goal, start small. Make sure you are setting yourself up for success.
• Limit alcohol. Too much alcohol can raise triglyceride levels and blood pressure.

Medications

Many people who have excess LDL cholesterol also need to take medicine to lower their cholesterol levels at some point.

This is especially true for people with atherosclerotic cardiovascular disease or those who are at high risk for developing it. 

Statins

Statins – in combination with lifestyle changes – are still the drug treatment of choice. Research has shown that the use of statins can reduce the risk of cardiac events like heart attack, stroke and related death. There are at least seven statins available, and they work in different ways; for example by:

• Reducing the amount of cholesterol made by the liver
• Removing cholesterol from the blood
• Reducing cholesterol in plaque
• Reducing inflammation from plaque
• Preventing plaque from dislodging or forming a clot that may block an artery 

As with any medication, it is important to tell your doctor about any side effects or problems from statins. Though side effects are not common, your doctor may decide to:

• Order a blood test to find out if there may be another cause of your symptoms
• Lower the dose of the statin you are taking
• Switch you to a different statin
• Prescribe an alternative dosing schedule 

Other Medications to Lower LDL

Other non-statin medications used to lower LDL-cholesterol include: 

• Cholesterol absorption inhibitors (ezetimibe) to lower the amount of cholesterol in the blood.
• PCSK9 inhibitors for high-risk patients who either have a cholesterol disorder passed down in families (called familial hypercholesterolemia) or who have heart disease but haven’t lowered their LDL-cholesterol levels enough even after taking the highest dose (amount) of statins (sometimes called maximally tolerated statin therapy) or ezetimibe.
• Bempedoic acid to block a slightly different step in cholesterol production than statins and is less likely to cause side effects on muscles sometimes experienced with statins. It is approved for use in high-risk patients with familial hypercholesterolemia or with heart disease who need to lower their LDL despite taking the highest dose of statins.
• Bile acid sequestrants or resins to bind cholesterol in the intestine and block absorption.

Medications to Lower Triglycerides

Also, medications to lower triglyceride levels might be used:

• High-dose omega-3 fatty acids lower triglyceride levels. Icosapent ethyl has been shown to lower recurrence of cardiac events in addition to lowering triglycerides. This is a prescription medicine.
• Fibrates and niacin mostly lower triglycerides but also lower LDL cholesterol to some extent.

It’s important to track your cholesterol and risk for related heart disease, heart attack or stroke. A simple blood test – called a lipid panel – is used to check the amount of cholesterol in your blood.

Cholesterol is measured in milligrams (mg) per deciliter (dL) of blood – mg/dL in the United States. The test provides four measures: 

• Total or overall cholesterol
• LDL, or “bad,” cholesterol
• HDL, or “good,” cholesterol
• Triglycerides

Lipoprotein (a) is another test that your care team may check to better understand your risk for stroke, heart attack or other diseases. It may be considered if you have early heart disease or a strong family history of early heart disease. 

It’s important to track your cholesterol over time, especially because there are often no signs and symptoms of early buildup of fat and cholesterol in the artery walls.

Talk with your health care team about how often your cholesterol should be checked and what numbers would be ideal for you.

Coronary Artery Calcium (CAC) Scoring

Coronary artery calcium (CAC) scoring, also called a coronary calcium scan, is a test that measures the amount of calcium in the walls of the heart’s arteries. 

Most of the calcium in our body is found in our bones and teeth. It helps keep them strong and healthy. But calcium in the arteries that supply the heart with oxygen and nutrients can spell trouble for our heart health. 

That’s because deposits of calcium in the coronary arteries are a sign that there may also be a buildup of plaque—a waxy substance that can harden over time and narrow or block the arteries (called atherosclerosis). When this happens, it makes a heart attack or stroke more likely. 

So a coronary calcium scan is one way to estimate someone’s risk of developing heart disease or having a heart attack or stroke.

A Type of Imaging Test

This test uses a special type of imaging test called a computed tomography (CT) scan of the heart. This scan produces multiple pictures to check if calcium is present and, if so, how much.

CAC scoring may also be called:

• Calcium Scan of the Heart
• Coronary Calcium Score
• Cardiac Scoring
• Cardiac CT for Calcium Scoring
• Calcium Scan Test

“Calcium itself is not necessarily bad. But having it in your arteries is considered a marker of having coronary heart disease. A lot of plaque can lead to a heart attack.” — Salim Virani, MD, FACC, and member of the 2018 Cholesterol Guideline writing committee.

Who Should Have CAC Scoring?

A coronary calcium scan can help you and your clinician better understand your future risk of having a heart attack, stroke or dying from one even if you don’t have any symptoms of heart disease.

But it’s most helpful in certain cases and for certain patients.

Most of the time, results from a physical exam, bloodwork and other tests will give you and your care team enough information to gauge your future risk of a heart attack or stroke.

The test is another tool that you and your care team can use when deciding what treatment is right for you. It can help determine if there are steps you should consider taking — beyond adopting healthy lifestyle habits — to lower your risk.

CAC scoring really comes into play when there is still some doubt as to whether your risk is enough to warrant taking a statin, which is a medication that lowers cholesterol. Statins are commonly used as the first medication of choice to lower low-density lipoprotein (LDL) cholesterol, or “bad” cholesterol.“CAC scoring can help give patients and clinicians more information to better inform decisions about whether a statin or other cholesterol medication might help.” — Martha Gulati, MD, FACC, CardioSmart editor-in-chief

CAC scoring is not recommended if you have:

• Low risk for heart disease (no risk factors) or
• High risk for heart disease or have heart disease already, or if you’ve already had a heart attack, stroke, stent or bypass surgery

CAC scoring also shouldn’t be used to assess whether treatment is working or not.

According to the 2018 Cholesterol Guideline, CAC scoring should be used only after you and your clinician have:

1. Assessed the likelihood of you having a heart attack, stroke or dying from one of these events in the next 10 years.This is called your 10-year risk score.
2. Taken into account other risk factors that could increase your risk, such as family history or certain diseases.
3. After steps 1 and 2, there is still some doubt about whether you should start a cholesterol-lowering medication.

CAC Scoring is Helpful for Intermediate Risk

If you are at intermediate risk of having a heart attack or stroke, CAC scoring may be helpful.

Low Risk	Intermediate Risk	High Risk
Few risk factorsLow calculated risk of heart disease or strokeNo symptomsNo existing heart disease	May have several risk factors, but there is uncertainty about whether a statin should be started	Multiple risk factors

What Do the Results Mean?

The test result is given as a number, called a CAC score. It can range from 0 to over 400. Your clinician can help explain your result and what it means.

Basically, the more evidence of calcium and thickening that is seen in the inside lining of the arteries, the higher the score. The higher your CAC score, the more likely you are to develop heart disease or have an event such as a heart attack or stroke. 

Keep in mind, though, this score tells us about the chance of developing disease. It’s not a guarantee. So, people with a 0 score could still have a heart attack, but the risk is very low. Similarly, people with a high CAC score aren’t certain to have a heart attack. This is why CAC scoring should be used together with other methods for estimating heart disease. 

What to Expect

A coronary calcium scan is often done in a hospital or other medical imaging facility. 

The test:

• Is fairly quick (it takes about 10-20 minutes  to complete)
• Uses a low dose of radiation
• Doesn’t require contrast — a special dye that is injected in your vein that is needed for some other imaging tests 
• Often includes an electrocardiogram (ECG), too

Be sure to let your clinician know if you are or could be pregnant before having this test.

What Increases Your Risk of Coronary Heart Disease?

It’s important to talk  with your clinicians about your risk for heart disease. This way you can decide together what you can do to lower that risk. 

The main risk factors for blockages in the heart’s arteries, called atherosclerotic cardiovascular disease or ASCVD include:

• Elevated LDL or total cholesterol 
• High blood pressure
• Diabetes
• Cigarette smoking
• Being overweight or obese
• Not being physically active
• Family history of early heart disease, heart attacks or stroke 

Many people don’t know that they have high levels of harmful cholesterol. That’s because there are usually no signs or symptoms associated with an early buildup of fatty plaques in the arteries.

Plaque is made up of cholesterol, fat and other substances. It’s not until there may be a large blockage of the artery that you might notice something is wrong. For example, you may have chest pain, pain in the arms or jaw, nausea, sweating, or shortness of breath. These usually occur when the blood supply to the heart or brain is being slowed or blocked.

Unfortunately, these blockages can rupture and cause major problems, even when they are much smaller and without causing any early symptoms. That is why, for some people, the first sign of elevated cholesterol may be a heart attack or stroke.

So – even if you’re feeling fine – it’s a good idea to get your cholesterol checked. Your care team will consider your cholesterol numbers along with any other factors that make heart disease or stroke more likely to occur, such as your age, if you have diabetes or  high blood pressure, of if you smoke. 

What Increases Your Risk?

High LDL and total cholesterol are generally related to either conditions passed on in families (inherited) or poor lifestyle habits that include:

• Eating unhealthy fats and simple carbohydrates
• Not exercising regularly
• Being overweight or obese

In addition, you have a greater chance of heart disease or a stroke if you have:

• High blood pressure
• Diabetes
• Family history of early heart disease
• Active smoking
• Low HDL-cholesterol levels (also called the “good” cholesterol)
• Or if you are Black or African American.

Cholesterol is a waxy, fat-like substance that travels through the blood.

Your body makes the cholesterol it needs. But you also get it from the food you eat (for example, full-fat dairy products, fried foods and fatty meat). Too much cholesterol can be dangerous.

That’s because over time cholesterol and fat can build up in the inner walls of the arteries that supply blood to the heart and other parts of the body. This can cause a narrowing of the arteries (atherosclerosis), which is a major cause of heart and blood vessel disease.

If you have high cholesterol, you’re certainly not alone. The good news is that high cholesterol is often preventable and treatable. Adopting a healthy diet, getting regular exercise and, in some cases, taking medication can go a long way to help lower your cholesterol and protect your heart.

Overview

While our bodies need a certain amount of cholesterol to work properly, too much of the “bad” type can be dangerous. Over time, cholesterol and fat can collect in the inner walls of the arteries – including the ones that supply blood to the heart.

This buildup can cause a narrowing of the arteries (atherosclerosis), which is a major cause of heart and blood vessel disease. People with too much low-density lipoprotein, or LDL, cholesterol – also called the “bad” cholesterol – are more likely to have a heart attack or a stroke.

Cholesterol is a waxy, fat-like substance that travels through the blood. Fats in some foods we eat gets made into cholesterol and is also made by the liver. It serves a variety of functions. For example, it helps create the outer coating of our cells and aids the body in making vitamin D and certain hormones. 

Extra dietary fats get absorbed by the body and raise bad cholesterol in the blood.

Saturated and trans fats also raise LDL-cholesterol levels in the blood and increase the chance of heart disease. Foods that are high in animal fat (full-fat milk, cheese, meat) or prepared with butter, shortening or partially hydrogenated oils and sweets (cookies and cakes) are often the main culprits.