Ask Dr. Mike: How Worried Should I Be About Cholesterol?

Mike Cirigliano, aka Penn’s Dr. Mike, who explains explains everything we need to know about high cholesterol

Meet internal medicine physician Michael Cirigliano, affectionately known as “Dr. Mike” to not only his 2,000 patients, who love his unfussy brilliance, tenacity, humor, and warmth (he’s a hugger!), but also to viewers of FOX 29’s Good Day Philadelphia, where he’s been a long-time contributor. For 32 years, he’s been on the faculty at Penn, where he trained. And he’s been named a Philadelphia magazine Top Doc every year since 2008. Now, he’s our in-house doc for the questions you’ve been itching (perhaps literally) to ask a medical expert who’ll answer in words you actually understand. Got a doozy for him? Ask Dr. Mike at victor@phillymag.com.

I know that I’m supposed to care about my cholesterol level, but I’m not entirely clear about why I’m supposed to care.
Well, by testing you, we can see how much cholesterol is in your bloodstream, and the reason we worry about high cholesterol is that it reflects a risk of coronary artery disease, which can tell us whether you’re likely to have a stroke or a heart attack down the road.

What can you tell me about the new cholesterol guidelines recently released by organizations like the American Heart Association?
Those guidelines tell us that we need to be much more aggressive when it comes to cholesterol — not just for middle-aged and older patients, but those much younger in life. When I started treating patients 32 years ago — oh, God, I’m getting old! — we would monitor your LDL (that’s your low-density lipoprotein, commonly known as “the bad cholesterol”) and an acceptable LDL level was 160. Now? Depending on how high risk you are, we want it to be less than 55.

That’s a big jump!
It is. The data clearly shows that people with high cholesterol end up having a higher risk of dying from it, and I believe in prevention. My approach to the Grim Reaper is that I wanna go and grab his gonads before he comes to my house and grabs mine. I take a really militaristic approach to all of this. The best defense is a strong offense. So, I want to test you and treat you as aggressively as possible because I really don’t want to get a call from you at 2 a.m. telling me that you are in the hospital having a heart attack.

You mentioned the “bad” cholesterol. Is there really a “good” one?
Historically, we’ve looked at HDL – that’s high density lipoprotein – as being something good. People who exercise a lot and don’t smoke have higher HDL numbers. But in my clinical approach, HDL does not negate me wanting to explore whether you have underlying coronary disease. There are people who “look” healthy — they are thin, they work out, they don’t smoke, they eat well — and then they have a heart attack on the treadmill and die.

How much advancement have we made in cholesterol since you started practicing three decades ago?
There is a tremendous wealth of information and tools out there. I now have a risk calculator called Prevent that takes into account your age, blood pressure, cholesterol, whether you have diabetes, whether you are a smoker — there are many factors that I plug in — and it will calculate not only a 10-year risk but also a 30-year risk as to whether you might have a heart attack or stroke.

So, if my cholesterol numbers are all good, can I stop worrying?
Well, I recommend that my patients get a calcium heart scan, also known as a coronary artery calcium or CAC test. This is a very quick visit to radiology, and they do a CT scan that shows me whether there is plaque in your arteries. Because your cholesterol numbers could look okay, but you might still have worrisome plaque in your arteries. Insurance probably won’t cover your CAC, but it’s $175 and totally worth it.

When we spoke about the new guidelines earlier, you brought up being concerned about cholesterol in younger people. Can you please elaborate?
A pediatrician should already be checking kids’ cholesterol levels because there some kids are actually born with very high cholesterol — it’s a genetic thing — and need to be treated very early in life. There’s also a genetic marker we can test for, the presence of which can indicate whether you have a higher coronary artery risk. I recommend everybody get that test once in their life.

But outside of that genetic marker and this fairly rare condition where kids are born with high cholesterol, at what age are you concerned about the cholesterol level of your patients?
Oh, this is something I look for in every single patient. I don’t treat kids, but if someone walks into my office at the age of 21, they are being monitored for their cholesterol. You can’t mess around with this stuff.

How do you combat high cholesterol in a patient?
First, dietary and lifestyle change. Exercise. Everybody needs to do that, and certainly if you have high cholesterol, you don’t want to be eating the wrong things — like highly processed foods — and you don’t want to be sitting around on your couch all day. Unless you want to die.

At what point do medications come into play for cholesterol?
When people are at high risk, statin therapy is something we need to look at. It lowers LDL by blocking an enzyme in your liver that produces cholesterol. Now, there’s a lot of gnashing of teeth about statins —

Oh?
There are concerns that maybe statins can cause dementia or diabetes, but some of that is rooted in misinformation. The fact is that statins are the number-one treatment for things like cardiac-risk reduction. But for people who say they don’t want to take a statin, there are other types of drugs. One is called Zetia, and the other is an injectable known as a PCSK9 inhibitors. So, there are options for people who don’t want statins or who simply don’t respond to them.

If I want to avoid high cholesterol, what foods should I likewise avoid?
I hate to be your personal Oppenheimer, your destroyer of worlds. But things that are greasy, things that are highly processed. It’s cookout season, so that means stay away from those hot dogs! Do I eat cheesesteaks? Yes, I do. But I certainly don’t eat them every week or even every month. And I try to go plant-based as much as possible. At the end of the day, all the foods we crave that make us happy to eat — the pizzas, the ribeye steaks, the bacon — are the ones that do us in. So go ahead and eat them. But in moderation. And exercise!