Cholesterol and atherosclerotic cardiovascular disease: Understanding the silent threat

October 25, 2023
By Dr Lim Bee Chian,
Consultant Cardiologist,
​Sunway Medical Centre
Cholesterol is a waxy, fatty substance found in the cell walls of various organs in our body, from the nervous system to the liver to the heart, which causes a blockage in your body’s arteries. This “bad” cholesterol can build up with other substances in the inner walls of arteries and cause narrowing and hardening of the blood vessels. A condition known as atherosclerosis that causes Atherosclerotic Cardiovascular Disease (ASCVD). The fatty deposits may also come loose and cause blood clots, resulting in a stroke or a heart attack.

A roadblock in the nation's health: The No. 1 killer
Malaysians are driving toward a healthy, long life, but a silent and relentless enemy stands in the way. Ischaemic heart disease, or coronary artery disease, is a blockade on the nation's road to wellness. In the context of ASCVD, the situation becomes even more urgent, like an urgent detour sign flashing. 

ASCVD and hyperlipidaemia are among the leading contributors to non-communicable disease (NCD) deaths in Malaysia, and despite these alarming facts, many Malaysians remain unaware of this symptomless disease's warning signs. 

World Health Organization (WHO) global estimates that over 15 million people die from ASCVD every year, accounting for 85% of global cardiovascular death. In Malaysia, this disease is like a pothole that causes 71% of premature deaths, with 4 out of 10 adults suffering from the bumps of high cholesterol levels. 

Disturbingly, Malaysians afflicted with cardiovascular disease are often ten years younger than those in advanced countries, with 25% below the age of 50. This rising prevalence of CVD-related illness and death doesn't just affect patients and their families; it also places an unsustainable economic burden on the nation.

Addressing ASCVD at the early stage and managing hyperlipidaemia is essentially crucial. Thus, there should be an urgency in stressing the importance of treating cholesterol to target, adopting a holistic approach, and overcoming fears toward medication. Lack of follow-through in treatment results in unmanaged cholesterol levels, leading to direct consequences. Yet, the reality is that in a nation where ASCVD is highly prevalent, Malaysians are generally ignoring all warning signs. 

The State of Health of the Nation survey conducted by the Malaysian Medical Association (MMA) and Novartis Malaysia revealed the misconceptions about cholesterol. 

92% believe that cholesterol can be controlled through lifestyle changes, 75% believe that high cholesterol has symptoms that we can detect the disease and 40% believe that cholesterol can be controlled through medications. 

Nevertheless, the fact is that high cholesterol is a 'symptomless' and invisible condition, only seeking medical help after a heart event or stroke. Detecting it earlier is not only better but vital for early prevention.

Key strategies for treatment and management include detecting high cholesterol early, treating cholesterol to target instead of range, and having a holistic approach that embraces newer breakthrough treatments and achieves the World Health Organization’s expectations of reducing cardiovascular mortality by 2025.

Many patients remain reluctant to start cholesterol-lowering medications due to fears or misunderstandings about treatments such as statins. The introduction of innovations like SIRNA (small interfering RNA) and PCSK9i offers new hope. 

Most importantly, the patient should understand that failing to control cholesterol to the standard will increase a person's risk of ASCVD and other related complications.

The silent epidemic
Delay and inadequate care leave patients at heightened risk for ASCVD-related events and complications, making this an urgent public health necessity. ASCVD presents an immediate and urgent crisis that requires a multifaceted approach to address. 

Once high cholesterol levels are detected in the health screening results, it is best to consult a specialist in cardiology to develop an appropriate management and treatment plan. Lowering cholesterol is an important measure to protect the heart and prevent atherosclerosis. 

Adjusting diet and lifestyle is not the solution to lowering the cholesterol level. It is best to consult a health practitioner for advice on the best way to lower/ control cholesterol. It is essential to understand the options for innovative treatment in lowering low-density lipoprotein cholesterol (LDL-C) to standard levels. It is one of the most effective ways to improve the health status of people at risk of ASCVD and even to extend the life of patients. 

Practitioners are encouraged to educate the patient to counter fear/fake news circulating on cholesterol treatments like statins. Statins are the most commonly prescribed medications to lower blood cholesterol and decrease your risk of dying, especially if you’re in one of the high-risk groups. These drugs can block the substances required for liver cholesterol synthesis, which helps to prevent cholesterol formation from the beginning.

For those who are intolerant to statin or failed to achieve the target goal of LDL-C despite a maximum tolerable dosage of statin, should consider other cholesterol-lowering treatment methods including cholesterol absorption inhibitors and some innovative therapies (such as PCSK9i inhibitors and siRNA therapy) that work well in treating cholesterol effectively, minimizing negative side effects and ensuring patient compliance. Cholesterol absorption inhibitors limit the small intestine's absorption of dietary cholesterol, which helps to reduce cholesterol in the blood. 

New injectable medicines may help the liver recover more LDL cholesterol and effectively reduce the amount of cholesterol in circulation. In some cases, doctors may consider combination therapy (combining statins with PCSK9 inhibitors or siRNA therapy) to lower the cholesterol levels in the blood. 

Ezetimibe is also a common medicine that is often prescribed with statin to lower bad cholesterol. This medicine works by preventing the absorption of blood cholesterol from the gut. The combination of statin and ezetimibe can bring about a 50% reduction in the LDL level (‘bad’ cholesterol).

Combination therapies can improve patient tolerance and compliance by improving efficiency and reducing side effects associated with higher doses, increasing tolerability and leading to higher adherence. A higher efficacy and adherence will result in a higher number of patients achieving recommended therapy targets, which currently are unacceptably low.

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