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DEAR DR. ROACH: I had a preemployment physical for my current position as a firefighter/EMT back in January. I had another preemployment physical for a new position with the fire department last month, and both physicians suggested a statin based on my high cholesterol. Both tests had similar results; my cholesterol was 272 mg/dL, my HDL was 52 mg/dL, and my LDL was 199 mg/dL. My other blood tests and electrocardiogram were fine.
I figured that I should probably try to get on a statin and manage the situation. I had a telehealth visit with a physician's assistant who put me on 40 mg of rosuvastatin and 10 mg of ezetimibe. The dose of rosuvastatin seems like a lot to me, but I wanted your opinion. I'm also taking two statins, which seems a little bit like overkill.
-- G.M.
ANSWER: Normally, when discussing the risks and benefits of statins, I start with an estimate of a person's risk, which can be estimated by one of the online calculators that are used both by patients and clinicians. However, the data are clear that in a person with an LDL over 190 mg/dL, the risk of an event is high enough that the benefits of treatment greatly outweigh the risks.
The new guidelines recommend statin therapy for a person with an LDL over 190 mg/dL even at age 30. Starting treatment at a younger age can slow or even prevent early damage to the blood vessels, which will ultimately result in a blockage of plaque. Plaque is made of cholesterol, connective tissue, cells, and protein components of blood clots.
In your case, 10 out of 10 cardiologists would recommend a statin, such as the rosuvastatin that you were recommended. The exact dose, however, is a matter of debate, with some experts reserving the high 40-mg dose for people with known blockages. Others argue that you might as well be treated with the most effective dose.
Ezetimibe isn't a second statin; it works by blocking the absorption of cholesterol from the gastrointestinal tract. Since statins reduce the manufacturing of cholesterol in the liver, the combination is highly effective. Again, not all clinicians would be as aggressive as your PA, but it's very reasonable for your cholesterol levels. Another approach would be to start you at a lower dose to try to get you down to an LDL goal below 70 mg/dL. (Some would say 50 mg/dL.)
Most people tolerate the combination of a high-dose statin and ezetimibe well, but more people will tolerate a lower dose that is titrated up, if necessary, to get to an ambitious LDL goal. Getting a primary care doctor to tailor your treatment to what you're comfortable with is a great idea.
YourGoodHealth@med.cornell.edu.
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