Cardiovascular health is so much more than having the “right cholesterol numbers”. At the core of heart health, we really need to be aware of the idea of healthy rather than oxidized cholesterol, and stress factors to the cardiovascular system. Research proves that you can still have heart disease even with “normal cholesterol numbers”. Knowledge about these concerns along with blood pressure management and information discussed in last week’s article Health Clues and Tips for Your Heart and Weight provide a guide for general well-being and heart health.

For decades, the focus with heart health has been all about cholesterol numbers. Yes, these numbers, i.e. total cholesterol, HDL, LDL, VLDL, and triglycerides do provide valuable pieces of information, but they aren’t the whole picture. Just like thyroid health is much more than TSH measurements, so is heart health.

Normal Cholesterol Does Not Indicate Freedom from Heart Disease 

You likely know or have heard of someone who had a heart attack even with great cholesterol and LDL levels. Despite the push to have “normal cholesterol numbers”, you can still have cardiovascular disease with normal cholesterol levels. This discrepancy shows that there are other factors at play with heart health. Significant evidence from the last few decades shows that other cardiovascular markers beyond cholesterol are more indicative of heart health or risks.

The common focus with cholesterol pertains to “bad LDL” or “good HDL”. The familiar scenario that you have probably experienced is that you get your cholesterol levels measured and find that LDL and/or total cholesterol levels are elevated. Your provider prescribes a cholesterol-lowering medication like a statin drug. Often, there is absolutely no mention of how healthy your cholesterol particles actually are.

Beyond the cholesterol panel, other markers with lipids and additional compounds provide much more insight into risk of plaque formation and cardiovascular disease. A broader picture of heart health and risks includes lab markers like LDL and HDL particle size, lipoprotein(a), ferritin, and others.

Cholesterol is not the “Bad Guy”

Cholesterol itself is used throughout the body as an antioxidant, to build cell membranes, and is needed for steroid hormone synthesis and other things. That’s why your liver produces 5-6 quarts of cholesterol per day. Cholesterol is not the “bad guy”; rather it is inflammation that injures lipid particles involved with cholesterol metabolism that raises significant risks for heart health. Evaluation of these lipid particles helps to evaluate cardiovascular risk.

Lipid Particle Types, Size, and Quantity

This shift in understanding cholesterol and lipid particles dates back to 1997. Researchers identified that small, dense particle size of LDL created increased risk of developing heart disease. This means that your LDL cholesterol number is more than just a numerical value. The bigger picture for heart health relates to the quality and quantity of the LDL particle.

LDL Particle Size: Big and Fluffy or Small and Hard

Healthy LDL cholesterol is big and fluffy like big fluffy snowflakes or puffy cotton balls. Damaged LDL is small and dense, like hard ice pellets or BB’s. When healthy LDL particles circulate in the blood, they flow through blood vessels gently bouncing along.

Damaged LDL particles (pellets) are abrasive to the thin inner endothelial lining of blood vessels. In response, your body reacts to the abrasion, releases immune and inflammatory compounds, and lays down cholesterol plaque on inner blood vessel linings for protection.

The quantity of small, dense particles makes a difference too. Your lipid particles might be like a sleet storm with small, dense pellets of ice coming down so hard and numerous that the ground is covered. Or, they might be like a picturesque light snowfall with some of the biggest, fluffiest snowflakes floating to the ground. Your basic cholesterol and LDL test does not measure LDL particle size or quantity. Healthy or damaged particles and quantity also applies to other cholesterol types.

To help protect your cholesterol and LDL particles, remove or reduce things that stress these compounds such as sugar, environmental toxins like heavy metals, solvents, pesticides/herbicides, food toxins like trans-fats, nitrates and nitrites, deep fried foods, smoking, and excess alcohol, etc.

Nutrient dense, antioxidant and polyphenol rich fruits and vegetables, complex carbohydrates with soluble and insoluble fibers provide fundamental dietary support for reducing damaged cholesterol. Simply changing a few key elements like removing refined carbohydrates in exchange for complex grains and legumes can make a difference in just a few weeks. Sugar, not saturated fat from quality foods, is especially detrimental to cholesterol health. 

Lp(a) – Strong Risk Factor

Cholesterol and triglycerides are transported throughout tissues by molecules called lipoproteins, which are lipids and proteins attached together. Lipoproteins transport cholesterol to various parts of the body for repair, structure, metabolism, receptor sites, and daily function. One lipoprotein of great interest is Lp(a).

Lipoprotein (a) or Lp(a), commonly called “lipoprotein little a” is a highly valuable cardiovascular risk marker. It is made by the liver and is a lipid marker like LDL cholesterol. Lipoproteins, like Lp(a), carries oxidized or damaged cholesterol particles.

Elevated Lp(a) levels are linked with inflammation and cholesterol deposits on the inner lining of blood vessels. High Lp(a) is thought to be primarily caused by variations in the LPA gene. The main organs responsible for clearing Lp(a) are the liver and kidneys.

Knowledge about your Lp(a) risk is important, as elevated Lp(a) levels are considered a strong independent marker for coronary artery disease/heart attacks or stroke even with normal cholesterol numbers. In 2010, researchers advised that Lp(a) be measured in all individuals who have a medium or high risk of heart disease, family history of elevated cholesterol, or early heart attacks especially fatal MIs, or recurrent heart disease despite statin cholesterol lowering treatment, etc.

Lp(a) levels over 20-30 mg/dL have been linked with a two-fold risk of heart attack. Statin medications do not lower Lp(a).

Lp(a) and Blood Sugar

Emerging research shows that even mildly elevated blood sugar levels with borderline Lp(a) increases cardiovascular events. In research affiliated with the American Diabetes Association, this 2019 study showed that individuals with elevated Lp(a) levels and mildly impaired glucose (pre-diabetic) levels had substantially higher risks and incidence of non-fatal and fatal heart attack or stroke. Diabetics with Lp(a) levels over 50 mg/dL had the greatest number of events or death. Blood sugar management must be made a priority to help take the burden off lipid management. 

Ferritin and Iron Stores

Ferritin is another compound that affects heart health. It is not a cholesterol particle or marker, but the balance of ferritin within your body can impact the quality of cholesterol and/or heart function.

Ferritin is a blood protein that contains iron and reflects iron stores within your body. Your heart is sensitive to your iron levels and requires a balance with iron. Ferritin levels provide insight into your iron stores and needs.

Mayo Clinic designates the normal range for ferritin as:

• For men, 24 to 336 micrograms per liter.
• For women, 11 to 307 micrograms per liter.

Optimal levels may be closer to mid-range 100-200.

Low Iron Stores 

Numerous studies have shown that diminished ferritin levels substantially stresses the heart in patients with heart failure. Individuals with heart failure and ferritin levels of less than 30, but normal hemoglobin levels, had a higher rate of mortality.

It is important to ensure that iron stores are adequate at all ages, including moms and unborn children, elderly, or those with vegetarian diets or other dietary challenges.

Adequate ferritin levels, or iron stores, are needed for red blood cells to transport oxygen throughout the body. If ferritin levels are on the low side, it impacts oxygen transport, which affects your heart muscle function, heart rate, skeletal muscles, blood flow, cellular respiration and mitochondria function. Your heart muscle needs iron for mitochondria to pass electrons back and forth and make ATP/energy for your heart to contract. Insufficient iron can interfere with normal cell clean-up or autophagy, which leads to a build-up of worn-out mitochondria in the heart.

You can learn more about the effects of low iron in the article Low Iron Linked with Muscle Health, Sleep Disorders, Mood, Stroke Risk, and Mitochondria.  

Excess Iron 

Too much iron, or high ferritin levels, also pose a substantial concern for the heart, as it can significantly stress the heart. High levels of iron stores in the body may occur from overzealous iron intake from iron rich foods or supplementation. High ferritin levels can also reflect acute inflammation, or some types of metabolic disorders. It can even be related with inherited disorders like hemochromatosis.

In hemochromatosis, iron absorption is increased. The hormone hepcidin, which is secreted by the liver, controls how iron is used and absorbed in your body. In hemochromatosis, this function is disrupted and results in increased iron storage. Over time, iron builds up in organs like the heart, pancreas, and liver and can cause damage with heart disease and blood sugar management, etc.

There are other ways that iron excess harms the heart. Iron excess can cause oxidative stress injury to LDL cholesterol, which changes the quality of LDL and contributes to coronary artery disease. It can also contribute to heart rhythm disorders, like atrial fibrillation and heart failure. Iron levels must be in a state of homeostasis – not too little or too much.

There are other markers that provide insight into cardiovascular health and the risk for plaque build-up in the blood vessels. They include homocysteine, hs CRP, interleukin-6 (IL-6), fibrinogen, thyroid hormone levels, and others. Rather than the quick jump to pointing fingers at cholesterol as the sole cause of your heart disease, a broader approach to the heart health puzzle should be properly evaluated, especially with familial or moderate or higher risk situations.

Heart health is more than shutting down cholesterol production. Your body’s health is far more complex. Your body needs adequate healthy cholesterol for numerous functions in the body. When cholesterol is too low, increased autoimmune inflammation, depression, and higher cancer risks occur.

In addition to a healthy lifestyle and stress management, incorporate plant-based antioxidants and polyphenols to aid in protection of lipids and cholesterol from free radical stress and daily oxidative wear. Use nutritional support to aid in blood sugar management. Health care is more than just number management. Make sure to look at the big picture as you look out for you and your loved ones.