THE HEART OF THE MATTER
a special program of the National Emergency Medicine Association (NEMA) 

Transcripts: 520-4 and 520-5

Week: 520.4 Guest: Louis Grenzer, M.D. Topic: HDL and LDL - Part One Host: Richard Roeder Producer: Ed Graham

ROEDER: This is the first half of a conversation about HDL and LDL with cardiologist Dr. Louis Grenzer from Baltimore, Maryland.

ROEDER: Dr. Grenzer, there are two little sets of initials and terms that are everywhere in the vernacular now - HDL and LDL and one is supposed to be bad and one is supposed to be good and it's very easy to get mixed up about which when you talk about things like cholesterol. First, would you just briefly define what they both mean and explain why one's good and why one's bad.

GRENZER: We used to measure just the total cholesterol and obviously if your cholesterol's high, that's not good. If your cholesterol's low, that is good. But several years ago, it was determined that the total cholesterol measurement can be a little confusing, a little misleading and so we have broken it down more recently and to what's called the good cholesterol and that's the HDL which stands for high density lipo-protein and the LDL which is the bad type of cholesterol - the low density lipo-protein and those two together along with the triglycerides make up the total amount of fat in your body. Now the significance is that we need to look at the LDL, the low density lipo-protein, the bad cholesterol and so what is normally done now is not just to measure the total amount of cholesterol but to break it down into the good cholesterol, the bad cholesterol and those two things can be looked upon sort of separately. We like to get the LDL, the bad cholesterol, down particularly in a patient with heart problems to under 130. We usually think of the total cholesterol as the normal being 200 or less but if you have a real high good cholesterol, that total cholesterol may look very misleading so it is important and I think most doctors that measure the cholesterol nowadays will automatically measure both the HDL and the LDL. Now as far as treatment, we have many drugs that will help you to lower your LDL and your total cholesterol. Unfortunately, the good cholesterol - there's not a whole lot we can do to make that higher. Exercise may help you to elevate the good cholesterol. There are a few drugs that are helpful in doing that but that's an area where we really need something better because in most cases we can't do a whole lot to alter that good cholesterol but we certainly have a lot of good drugs that will lower the amount of the bad type of cholesterol in your blood.

NEMA: Is there any doubt that as we speak at this time in medical history that diet affects LDL?

GRENZER: Diet is an interesting thing to talk about. We always, or it's always been recommended that we always first try a patient on a diet if they have a high LDL, a high amount of bad cholesterol in the blood and diet will probably only lower your cholesterol maybe 5% or so.

NEMA: Join me for the second half of a discussion on HDL and LDL with Dr. Louis Grenzer.

Transcripts:

Week: 520.5 Guest: Louis Grenzer, M.D. Topic: HDL and LDL - Part Two Host: Richard Roeder Producer: Ed Graham

NEMA: This is the second half of a conversation about HDL and LDL with cardiologist Dr. Louis from Baltimore, Maryland. I asked Dr. Grenzer about diet and LDL.

GRENZER: Even a fairly strict diet will probably only lower your cholesterol maybe 5% or so. If it's 200, 5% it would go down to 190. I heard one of the experts on cholesterol at a meeting I went to recently say just that. Diet will lower you from 200 to 190. He said big deal. He was advocating doctors using the drugs a lot more than we are because one of the dangers is that people are told to follow a diet. They come back and the cholesterol is either the same or a little lower. They don't want to go on the medicine so they talk the doctor into extending them out another few months trying the diet. Years go by and the patient still has high cholesterol so my thinking and it's certainly the thinking of a lot of other cardiologists nowadays is that if an initial trial of the diet isn't getting that cholesterol down, we really ought to go to the drugs and do something that's going to be effective. The drugs are actually much more effective than diet and so I think there's a danger in going along too long with a diet when it's really not doing the trick. We're under treating people as far as high cholesterol nowadays. Even cardiologists aren't treating cholesterol probably as aggressively as they should. There's no doubt that in patients who have had a heart attack or have chest pain or angina that lowering the cholesterol prevents them or has a tendency to prevent them from having events such as heart attacks, hospital admissions and so forth.

NEMA: Historically, the recommended high end of the acceptable cholesterol number has come down from where it was ten, even five years ago. Do you think it's bottomed out where it's going to remain right now or do you think it's even going to be recommended that patients get their cholesterol even lower?

GRENZER: It's interesting. I have patients who I've seen for 20 years who when I look back at their chart, their cholesterol back 15, 20 years ago was 300 and if you look at the normal according to the lab, they were normal. 300 was normal. Nowadays we think of that as an extremely high cholesterol. Over the years, that's gradually come down and I guess the number that is accepted now is about 200 with 200 to 240 being borderline. The interesting thing is that the average cholesterol of a patient coming in the hospital with a heart attack is only 225. There's lots more people having heart attacks that have slightly elevated cholesterol than those with the cholesterol that's 300 or 350. The reason for that is there's a lot more patients with cholesterol's that are slightly elevated. The patients with the real high cholesterol are also at risk but we can do just as much bringing the cholesterol down from 225 to 200 or less as we can treating that patient with the very high cholesterol and certainly some cardiologists aren't really looking at that 200 number anymore. They're trying to get it down even lower than that - 150 or an LDL of under 100.