Heart attack happens due to sudden occlusion in coronary artery which supply blood to the heart muscle and the reason why the artery gets suddenly occluded is because of clot formation over a cholesterol rich plaque. That explains that the bad lipids are the main cause of coronary plaque formation which many times leads to major heart attack.
In my clinic, the patient who unsettles me most is the 36-year-old man with a heart attack, a normal waistline and no idea his cholesterol was the problem. Indian men develop coronary disease roughly a decade earlier than their Western counterparts. So what is the reason?
There are multiple reasons for development of cholesterol rich coronary plaques. High blood cholesterol is the most common reason although is not the only reason. Many other situations like family history of premature heart attack (genetic inheritance of bad genes), tobacco consumption, diabetes, systemic hypertension, obesity, stress, etc. can lead to coronary artery disease. However high baseline cholesterol remains the number one reason for coronary plaques and it is worth trying to reduce it by whatever means.
So the question is fair: can the newest cholesterol drugs help people who are still young?
For decades, statins have been the main cholesterol medicine. High intensity statins can reduce the LDL cholesterol by 50 per cent. The newer treatments are for people who need more than a statin can deliver. These include,
- PCSK9 blockers. PCSK9 is a protein that destroys the liver’s “cholesterol vacuum cleaners,” the receptors that pull harmful LDL out of your blood. Blocking it lets the liver clear more LDL. These come as injections, and now as a tablet. The injection is given once every 15 days. It can reduce the LDL cholesterol by 50 to 65 per cent. Along with statins, it can reduce LDL cholesterol by 85 per cent
- Inclisiran. It switches off the instruction to make PCSK9 in the first place. It is given as an injection just twice a year. It alone can reduce the LDL cholesterol by 55 per cent.
- Bempedoic acid. A tablet that reduces cholesterol production in the liver. It is mainly useful for people who cannot tolerate statins. It can reduce the cLDL cholesterol by 30 per cent.
- Lipoprotein(a) drugs. Lp(a) is a cholesterol particle you inherit from your parents, and South Asians often carry high levels. Drugs aimed at it are still in trials.
These drugs are not for everyone. They are used mainly by:
- People with an inherited cholesterol disorder (familial hypercholesterolemia)
- Heart attack or stent patients whose LDL stays high despite a statin
- People who cannot take statins because of side effects
- People with very high Lp(a)
In India, cardiologists have welcomed inclisiran and PCSK inhibitors. But the high cost of these drugs tempers its use.
They are very effective at lowering LDL. For Inclisiran, a small Indian real-world study of 65 patients reported a drop of about 70 per cent after three months, though those patients averaged 57 years of age. However, larger studies are awaited. The new PCSK9 tablets lower LDL by 56 to 59 per cent, when compared with a placebo.
But lower LDL numbers are not the same as fewer heart attacks. Only more long-term studies will reveal that. The reasoning behind acting early is sound. Genetic studies suggest that the longer your LDL stays low across your life, the greater the protection. Think of LDL as sludge building up in your pipes: the more years of exposure, the more buildup. But no large trial has tested these drugs specifically in young men.
Despite the availability of these new medicines, prevention always comes first, and medication is added when it is not enough. These include not smoking or using tobacco, regular exercise and a healthy waistline, a diet low in fried food, refined carbohydrates and sugar, good sleep and controlled stress and managing blood pressure and blood sugar.
It is more important than ever to know your numbers early. A full cholesterol profile and a one-time Lp(a) test are worth doing by age 30, especially if a close relative had a heart attack before 55. These drugs are powerful tools, but they work best alongside healthy habits, not instead of them.