EP223: Cholesterol Therapy in 2022

Welcome to my podcast. I am Doctor Warrick Bishop, and I want to help you to live as well as possible for as long as possible. I’m a practising cardiologist, best-selling author, keynote speaker, and the creator of The Healthy Heart Network. I have over 20 years as a specialist cardiologist and a private practice of over 10,000 patients. Podcast Summary Dr. Warrick Bishop is a practicing cardiologist and author dedicated to educating patients about heart health. In this episode, he provides a comprehensive update on cholesterol therapy in 2022, addressing the confusion surrounding cholesterol management and discussing current and emerging treatment options. The episode emphasizes that while cholesterol lowering is clearly beneficial for high-risk patients with existing plaque buildup, there remains reasonable debate about preventative treatment in otherwise healthy individuals. Key Takeaways: For high-risk patients who have experienced a heart attack or stroke, lowering cholesterol definitively reduces future cardiovascular risk, and lower cholesterol levels show no clear threshold of being "too low." Statin side effects, particularly muscle aches and pains, occur in 5-15% of patients and are dose-related, meaning higher doses carry greater risk of side effects. Ezetimibe is an underutilized, generic, and affordable medication that works synergistically with statins by binding cholesterol in the gut, providing better cholesterol reduction than higher-dose statin monotherapy. PCSK9 inhibitor monoclonal antibodies (injected fortnightly or monthly) can reduce LDL cholesterol by up to 60% through a different mechanism than statins, offering powerful cholesterol control for high-risk patients. Inclicerene, an mRNA interference drug targeting PCSK9, is nearing completion of clinical trials and offers approximately six months of sustained LDL reduction from a single injection—similar conceptually to a vaccination against heart disease. Bempedoic acid is an emerging therapy that works upstream of statins via a liver-specific pathway, potentially offering an alternative for patients experiencing statin muscle intolerance without affecting muscle tissue. Gene-editing RNA therapy and other novel agents like Evanacumab (angiopoietin-like-3 inhibitor) are in development and represent an exciting future for cholesterol management, with primate studies showing potential for lifelong cholesterol reduction. The broader challenge is that many high-risk patients are not currently meeting cholesterol targets despite available medications, indicating a gap between current treatment options and their actual utilization in clinical practice.