Hello Mr GV Tharakan,
Thank you for your query.

As you have rightly pointed out, the total cholesterol, triglycerides and the LDL cholesterol levels are all high. HDL cholesterol level (the good cholesterol) is acceptable.

The target values are as follows:

Total Cholesterol < 200mg/dl
Triglycerides <150mg/dl
LDL cholesterol <130 mg/dl
(If you are a diabetic, the LDL cholesterol should be less than 100 mg/dl, and if there are multiple cardiac risk factors, unstable Coronary Artery Disease, kidney disease and very high cardiac risk, then the value should be less than 75mg/dl. There are experts who strongly believe that Indians as a race are strongly predisposed to heart disease and thus, stricter LDL limit of < 75mg/dl is better!)

Since you have a family history of heart disease and since you are an Indian male with high cholesterol levels, you are at a higher than normal risk for developing coronary artery disease, cerebrovascular disease and peripheral vascular disease.

Treatment should consist of dietary regulation, daily exercise and drugs. You also need to monitor and control your blood sugar, BP, weight and avoid exposure to smoking (active and passive).

Tonact TG is a good drug which combines atorvastatin and fenofibrate to control LDL cholesterol (bad cholesterol) and triglycerides.

You need to repeat a fasting lipid profile towards the end of two months, while still on the drug. Based on the values, the drug dosage will need to be adjusted further. You will probably need to continue the medicine for a longer period of time. The important thing is to keep the cholesterol values as low as possible and within the target values to prevent disease later on.

A negative treadmill test indicates that you have a low probability of having significant obstructive coronary artery disease. Significant disease is usually defined as having major blocks of more than 70% severity.

It does not predict the probability of heart attacks (which can occur with even 40% to 60% blocks, when blood clots suddenly after coming into contact with cholesterol deposits after a break in the inner lining of the coronary artery).

Unfortunately, there is no practical test at the moment to identify these "vulnerable plaques" that can produce heart attacks. Prediction of heart attacks and strokes are currently based on risk estimation depending on age, gender, race, smoking, diabetes, hypertension, lipid abnormalities and family history. The best way to reduce risk is a multi-pronged approach focussing on diet, exercise, drugs and lifestyle modification to target the "modifiable" risk factors. (You obviously cannot prevent getting older, being a male, change your genes or your parents!!)

I hope this answers your query. Feel free to ask me any clarifications that you may require.

With regards,
Dr Raja Sekhar Varma, MD, DM,
Consultant Interventional Cardiologist

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Hello,
Thank you for the query.

The lipid profile has to be done on a fasting basis. Ideally, around 10 hours of fasting is enough (usually, overnight fasting after dinner, and blood test done the next day morning). It is better to have absolute fasting, though sips of water will not matter.

Diet can influence the triglyceride levels a lot. These changes can come within 3 months also.

Needless to say, the test should be done properly in a good, standard lab using direct estimation of lipid levels. Some labs measure only total cholesterol, triglycerides and HDL cholesterol and calculate the estimated LDL and VLDL levels. This can be erroneous.

It is also known that there is a lot of variability in the test results depending on the weather (in the cold season, you may get lower values), gender, liver function, thyroid function, blood sugar levels, etc.

Thus, it becomes necessary to perform the test at a standard, quality-conscious lab with good accreditation and internal/external quality control. Fasting is important. Blood sampling and processing should be standardized. There should not be technical errors in loading the auto-analyzer. The kits used should have been standardized and machines calibrated properly. There should not be too much delay in processing the sample.

Since the total cholesterol and LDL appear to be high in both the reports, and since you have started on medication, it is better to wait for 2 months and then recheck your lipid profile. Do not stop the medication prematurely. The medicine will need to be modified/dosage adjusted after the lipid profile result.

Sine the treadmill test is negative, there is no immediate necessity of doing an echo or CT angiogram, unless there is strong clinical suspicion of heart disease, other uncontrolled cardiac risk factors and symptoms of chest pain, breathlessness on exertion, palpitations or giddiness. Since the echo is a non-invasive, cheap and harmless investigation, there is no harm in doing an echo either. But angiogram, whether conventional or CT, is reserved for those with appropriate symptoms, strong, multiple uncontrolled risk factors and positive stress test.

I hope this answers your query.
Please accept my answer if there are no further clarifications.

With regards,
Dr RS Varma

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