Bridging the care gap: The importance of lowering your cholesterol after a heart attack

If you have a history of heart attack or stroke, staying below the recommended cholesterol threshold is one of the most important things you can do to prevent a future cardiac event.

If you have too much of the “bad” low-density lipoprotein cholesterol (LDL-C) in your bloodstream, it can cause a buildup of plaque in the arteries. As the buildup grows, it can lead to hardening of the arteries, which increases your risk of atherosclerotic cardiovascular disease (ASCVD), a group of conditions including heart attack, stroke and PAD, which is the narrowing of the arteries in the legs and arms (among others). ASCVD is the second leading cause of death in Canada.

Our recent Canadian study, Real-World Risk of Recurrent Cardiovascular Events in Atherosclerotic Cardiovascular Disease Patients with LDL-C Above Guideline-Recommended Threshold: A Retrospective Observational Study, reveals that, even with therapeutic advances, many heart attack and stroke survivors in Canada are failing to meet their recommended cholesterol threshold. As a result, many of these individuals continue to experience repeat cardiac events.

But with increased education and cholesterol management among patients and their health care teams, this trend can be reversed. “This is easily and safely managed and can be prevented,” says Dr. Shaun Goodman, a staff cardiologist and associate head in the Division of Cardiology, Department of Medicine, at St. Michael's Hospital. “We know that there is a very strong relationship between whether you hit your threshold for your LDL cholesterol and your cardiovascular outcome risk,” added Dr. Goodman, one of the lead authors of the study.

Increased risk for heart attacks

Our study examined administrative health data from approximately 33,000 patients in Alberta, Canada, with a history of ASCVD, including a recent heart attack, stroke, or peripheral artery disease (PAD) and who were at high risk of another CV event.” While patients were prescribed the statins indicated to manage their cholesterol, many still had LDL-C levels above the Canadian Cardiovascular Society (CCS) guideline-recommended threshold levels. The CCS guidelines recommend that patients with ASCVD keep their cholesterol levels below 1.8 millimoles per liter (mmol/L).

Patients in this study who remained above their LDL-C threshold despite cholesterol treatment unfortunately often had serious consequences. For example, one in five patients with LDL-C levels above guideline-recommended thresholds experienced a repeat cardiovascular event, such as a heart attack or stroke. Furthermore, in some very high-risk groups (patients with a recent heart attack), more than half of individuals who remained above their cholesterol thresholds experienced another cardiac event within three years. During the three-year study duration, 1 in 10 of these patients died from cardiac causes.

Know your numbers

If you have ASCVD, it’s critical to take an active role in managing your cholesterol to prevent a future cardiac event. The study indicates that it’s important to know your cholesterol levels and ensure you are getting checked regularly. Your goal should be to bring down your LDL-C to below the 1.8 mmol/L threshold.

If you’re not at the recommended level, ask your doctor about different treatment options for lowering your LDL-C. Approximately 40% or more patients may need an additional treatment beyond what they’ve been prescribed upon leaving the hospital, says Dr. Goodman. For patients with ASCVD struggling to meet their cholesterol threshold with the recommended first-line therapy, the CCS advises that you add an additional lipid-lowering therapy under the guidance of your doctor to help further lower cholesterol levels.

“Be your own advocate and make sure that in four to six weeks after your event and starting on cholesterol-lowering treatment, you get your cholesterol levels checked again,” says Dr. Goodman.

A complementary approach

Beyond taking medications, making lifestyle changes such as getting regular exercise, managing stress, and maintaining a healthy diet are an important part of managing your cholesterol. When making diet and exercise changes, it’s important to be realistic and make small changes that you’re more likely to stick with. “This isn’t all-or-nothing,” says Dr. Goodman. "It’s a complementary combination of diet, lifestyle, exercise and treatment you should discuss with your doctor.”

And keep in mind that for some people, changing your diet alone (without the help of medications), may not be enough to meet your LDL-C threshold. The liver naturally produces cholesterol, and many people have a genetic predisposition to produce excess “bad” cholesterol.

“For these patients, lifestyle changes alone may not be sufficient to lower LDL-C levels below the recommended threshold. There are genetic and other risk factors that make some people predisposed to produce bad cholesterol and to be at a higher risk for heart attacks and strokes; unfortunately, their cholesterol levels are too high for their arteries. It’s not their fault,“says Dr. Goodman.

Closing the care gap

Despite the growing evidence that shows the benefits of maintaining LDL-C below threshold levels, there’s still a significant care gap in Canada.

Several factors contribute to this care gap. Many patients, and even some clinicians, are not up-to-date on the latest clinical guidelines. For instance, many are unaware that the LDL-C threshold is 1.8 mmol/L for patients at high risk for a cardiac event. Cost and access to these treatments remain barriers for some patients. In addition, convincing patients to take an additional medication when they’re feeling fine can be challenging. Many patients who are already taking multiple medications for other conditions are resistant to add one more therapy to lower their cholesterol, according to Goodman.

In order to overcome many of these challenges, it’s important to put patients at the center of their care. This includes working closely with them to ensure that they have their LDL-C levels checked regularly and that they understand the risks of not maintaining below threshold levels. “If we make the patient the center of this, I believe we have a better chance of transmitting this information.“ says Goodman.

Be your own advocate

If you’ve had a heart attack or a stroke, you’re the number-one person who can help prevent it from happening again. Starting from the day you leave the hospital, it’s critical to begin thinking about managing your cholesterol levels. Be sure to have your cholesterol checked regularly, and if you’re having challenges meeting your recommended threshold, ask your doctor for treatment options.