Woman Has Heart Attack Despite Very Low Cholesterol

A study in the New England Journal of Medicine (Aug. 21, 2024) reveals three biomarkers that may be very important in predicting heart disease in women for the next 30 years. The research demonstrates that inflammation and a rarely-measured blood lipid called lipoprotein(a) [aka Lp(a)] are critical along with LDL cholesterol. Researchers analyzed high-sensitivity CRP [C-reactive protein], LDL cholesterol and Lp(a) levels in the 1990s for nearly 30,000 participants of the Women’s Health Study. Thirty years later, these healthy middle-aged women had experienced more than 3600 cardiovascular events including heart attack.

People with the highest levels of CRP were 70% more likely to have had a heart attack or other cardiovascular event. High levels of LDL cholesterol increased the risk by 36%, while women with high levels of Lp(a) were 33% more likely to have had a heart attack or stroke.

A Heart Attack with Low Cholesterol!

This reader proves that a heart attack can occur even when total cholesterol is low:

Q. I thought you only got heart disease if you had high cholesterol. My friend, a woman 53 years old, had a heart attack even though her cholesterol was 141 (HDL 49, triglycerides 124 and LDL 67).

There’s no heart disease in her family, she did not smoke and had low blood pressure. And yet she is scheduled for open heart surgery because she has four blocked arteries. Is there anything she could have taken to protect herself? I don’t want to have a similar experience.

A. Half of all heart attacks occur in people with normal or even optimal cholesterol levels. A fascinating study published in the American Heart Journal (Jan. 2009) revealed that roughly half of the 140,000 patients hospitalized with a heart attack had LDL cholesterol levels around 100 at the time of admission, which is considered quite good. According to the lead researcher, Dr. Gregg Fonarow, “almost 75 percent of heart attack patients fell within recommended targets for LDL cholesterol…”

Clearly, cholesterol is not the only factor determining heart disease. Your friend would have been considered a very low risk for a heart attack based upon her lipid levels. Her total cholesterol of 141 and her LDL cholesterol of 67 would have been considered excellent by most cardiologists.

What we do not know is what her Lp(a) levels were or how much inflammation she was experiencing (as measured by high-sensitivity CRP).

Other Risk Factors for a Heart Attack

An editorial in the New England Journal of Medicine on November 14, 2002 by the director of the preventive cardiology program at Columbia Medical Center, Lori Mosca, MD, MPH, PhD, stated: “More than 20 years ago, 246 risk factors for coronary heart disease (CHD) had already been identified, and the number continues to grow.”

Did you get that? Over 30 years ago physicians knew that there were more than 246 factors that could contribute to heart disease. By now it is likely that there are over 300 risk factors linked to coronary artery disease. And yet total cholesterol and LDL cholesterol remain the primary determinants of whether a patient will be treated with statins.

Here are just a few other important determinants of heart disease risk:

• C-reactive protein (CRP)
• Lipoprotein (a) or Lp(a)
• High uric acid levels
• Insulin resistance
• Depression
• Stress and anxiety
• Anger and hostility
• Low levels of physical activity
• Hormone replacement therapy (HRT)
• Low levels of testosterone
• Marital strife
• Loneliness

Was your friend was asked about her psychological situation vis a vis depression, stress, anxiety or loneliness? Did anyone inquire about her social support? Was she tested for insulin resistance?

Although exercise is key to good health, it doesn’t always protect people from a heart attack. Many years ago we received this communication:

“I am a 44-year-old male and an active masters swimmer. I have always eaten a low-fat diet and have a total cholesterol of 160. For all intents and purposes I’m the picture of health.

“However, I recently survived a heart attack caused by a blood clot blocking one coronary artery. Further testing showed that my HDL level is low (25) and my level of Lp(a) is very high (80). I’ve been told that these risk factors could help explain the heart attack.”

What this means is that heart disease is way more complicated than LDL cholesterol. Anyone who would like to learn more about the other risks factors and ways to modify them may find our eGuide to Cholesterol Control & Heart Health of benefit. This electronic resource can be found under the Health eGuides tab.

Share your own story below in the comment section. Have you had your Lp(a) levels measured. What about CRP? They may be at least as important as LDL-C. An anti-inflammatory diet could be beneficial in lowering CRP levels.