A Tale of Two LDL's

Kurt, a 50-year old businessman with a heart scan score of 323, had a :

--Conventional (calculated) LDL of 128 mg/dl
--Real measured LDL 241 mg/dl.

Laurie, a 53-year old woman who underwent a coronary bypass operation last year (before I met her), had a:

--Conventional LDL of 142 mg/dl
--Real measured LDL was 85 mg/dl.

(By "real, measured" LDL, I'm referring to LDL particle number in units of nmol/L obtained through NMR lipoprotein testing and dividing by 10, or just dropping the last digit to convert the value to mg/dl. This technique was arrived at by comparing the population distributions of these two parameters, LDL particle number and calculated LDL. This is the gold standard in my view. Similar numbers can be obtained by measuring apoprotein B, direct LDL, or calculated non-HDL, with diminishing reliability from first to last.)

In other words, Kurt's conventional LDL underestimated real LDL by 88%. Laurie's conventional LDL overestimated real LDL by 40%.

Interestingly, Laurie's doctor had insisted she take Lipitor for a high LDL cholesterol. Her real LDL was, in fact, low to begin with and benefits of a statin drug would be little to none. (Remember, in our Track Your Plaque approach, multiple other treatments are included, such as omega-3 fatty acids from fish oil, vitamin D normalization, and wheat elimination, strategies that yield benefits that others expect to obtain with statins.) Laurie's real cause of her heart disease proved to have nothing to do with LDL cholesterol, but involved lipoprotein(a) and thyroid issues.

Kurt proved to have a severe preponderance of small LDL particles--the worst kind of LDL, while Laurie had none--a benign pattern.

Then how can anyone make sense of the conventional, calculated LDL cholesterol that is generally (95% of the time) provided? If accuracy can stretch to plus or minus 80% . . . you can't. Conventional LDL is a miserably inaccurate number. The problem is that obtaining a superior number requires a step or two more testing and insight, something most busy primary care doc's simply don't have in the midst of a day filled with arthritis, bronchitis, diarrhea, belly aches, and seborrhea.

Yet conventional--I call it "fictitious"--LDL serves as the basis for this $27 billion (annual revenues) industry selling statin drugs.

This is meant to be neither an argument in favor of nor against statin drugs. However, it is plain as day that any study designed to reduce LDL cholesterol will be hopelessly clouded by calculated LDL imprecision. A calculated LDL of, say, 143 mg/dl might really be 187 mg/dl, or it might be 74 mg/dl--you can't tell by looking just at LDL. Yet billions of dollars of research and billions of dollars of healthcare costs are based on the treatment of this number.

This reminds me of the mark-to-market accounting magic that helped topple Wall Street.

I don't think that the statin world is poised for such a huge downfall. But I do see this as a source of enormous dilution of the effects of statin drugs. People who barely stand to benefit get the drugs, while others who might truly benefit are treated inadequately. It provides fuel to the growing idea that reducing LDL cholesterol fails to truly provide benefit.

I am no lover of statin drugs nor drugs in general. But I am a fan of knowing the truth. Despite my bashing of the drug industry (and make no mistake: the drug industry is a cutthroat, profit-seeking, do-anything-to-increase-sales industry), I do believe that there is a role for statin drugs (though far smaller than $27 billion per year). But the usual method of selecting people for treatment is pure fiction. The ATP-III cholesterol treatment guidelines? An anemic attempt to apply structure to meaningless values.

You and I do not need to subscribe to this sort of non-quantitative nonsense.

Comments (10) -

  • renegadediabetic

    1/15/2009 3:22:00 PM |

    It's just part of big pharma's racket.  The public has been propgandized to fear cholesterol, statin prescriptions are based on an antiquated calculation, and the people who set cholesterol targets have financial ties to the drug companies.  This has created a big cash cow for big pharma.

    The only people to benefit from statins are middle aged men who have had a heart attack and even then, the benefit is small.  If statins were restricted to those who would truely benefit, it would mean a lot less $$$$ for big pharma.

  • Alan S David

    1/15/2009 3:31:00 PM |

    Today's news said millions more Americans over 60 could benefit from statins to combat the c-reative protein problem. How many more so called great things will statins do for us? Is this another terrific marketing ploy?

  • Zbig

    1/15/2009 8:52:00 PM |

    Dear Doc,
    all this NMR is black magic to me so far, besides I will wait for some advanced lipid measurements until I am at least 40.
    But I suspect that the LDL size can be guesstimated from e.g. triglicerides / HDL ratio - could you please supplement your post with the figures for both persons. I suspect there will be a difference there. TIA

  • Steve L.

    1/16/2009 3:36:00 AM |

    And if a million or so "Lauries" are given Lipitor for their 85 mg/dl  real LDL, I don't expect their all-cause mortality will IMPROVE .

  • Richard Nikoley

    1/17/2009 5:43:00 AM |


    My speculation is that this is merely an effect of the huge to-market costs pharmaceutical companies must endure, owing to FDA regulations.

    If people didn't have false-security -- as you have shown -- of FDA hurdles and implicit [expensively purchased] assurances, they might just take a bit more proactive, intelligent and informed approach to their own health, and maybe drug companies might go back to serving an informed consumer who no longer simply bows to an authority (the FDA) because they have the power to be who they are.

  • jean

    1/17/2009 5:57:00 AM |

    My neighbor is being lipitor by his internist because both his parents have alzheimers. At least that is what my neighbor told me.  I told him I'd never heard of that and he said he'd trust the doctor to know.

  • Robin

    11/2/2012 4:58:02 AM |

    Statins don't lessen the risk of heart disease by lowering cholesterol. They work by lowering inflammation which is not what  they were designed to do and was not expected. Happens a lot - drugs being created for one thing and being found to work for something else so are then subscribed for other conditions.

    Statins are powerful and dangerous drugs that block the production of cholesterol. Our bodies NEED cholesterol. By blocking its production, it also blocks Co Q10 and dolichols, and more. Side effects range from minor muscle pains to the complete destruction of muscles, kidney failure then death. Also transient global amnesia (TGA) which doesn't show up immediately and is dismissed when it does. They cause depression and violent behaviour. That's why people on statins have a higher morbidity from all other causes and not heart attacks.

    As renegadediabetic  above says, they show slight benefit for middle-aged men who have already had a heart attack. Oh yeah, tell us again why we need them?

  • Robin

    11/2/2012 5:00:24 AM |

    "morbidity"? Um, mortality.

  • Robin

    11/2/2012 5:01:59 AM |

    Darn. Message went to wrong place. Mortality is what I meant.