If my cholesterol is less than 200mg/dl, within normal limits, should I worry about heart disease?

When 45-year-old Arjun Mishra* was brought into the emergency room with a heart attack and required immediate stenting, he was perturbed. For only a week before, his full body check-up reports had shown that his total cholesterol was less than 200mg/dL. But the reality is that optimal cholesterol levels don’t always guarantee heart health because the proportion of bad cholesterol in the bloodstream can still lead to plaque build-up in the arteries.
“No cholesterol limit can be considered safe. The commonest make that people make is to consider the total cholesterol count as a measure of good health. But the fact of the matter is that you have to see individual components, particularly the LDL (bad cholesterol) count, the proportion of HDL (good cholesterol) and the HDL:LDL ratio. Indians have a low HDL. They say 50mg/dL is ideal to neutralise LDL but in Indians, that level never crosses 45 mg/dL. Which is why we should only focus on the LDL levels and keep them low. In fact, over the last three decades, the safe limit for LDL has been pushed down and for Indians, who are genetically prone to cardiac conditions, the LDL levels are the only concern,” says Dr Balbir Singh, Chairman, Cardiac Sciences, Cardiology, Cardiac, Electrophysiology-Pacemaker, Max Hospital, Saket.
What’s the safest LDL number that is required?
“Internationally, they prefer LDL levels to be less than 70 mg/dL but for Indians, I would say less than 50 mg/dL. Heart disease among Indians is compounded additional risk factors like family hory, smoking, stress, hypertension and diabetes. So many young Indians are getting a stent in early ages,” he says.

The other worrisome factor is triglycerides. “LDL levels need to be reworked for some people in combination with co-morbidities, high triglycerides and body weight. Triglycerides are blood fat, which along with cholesterol, cause plaque build-up. Therefore, both triglycerides and LDL levels need to be significantly lower,” says Dr Singh.
In fact, the Johns Hopkins recommendations say that LDL can be even more risky in women compared to men. “This is a problem because women’s cholesterol levels can fluctuate quite a bit after menopause and tend to increase with age, putting them at greater risk of heart disease and stroke. Knowing your cholesterol numbers and how to control them is a big step toward staying healthy,” it says.
“The LDL particles like to stick to the lining of your arteries, like soap scum in pipes. As it sticks there, it generates an inflammatory response and your body starts converting it into plaque. Plaque in your blood vessels makes them stiffer and narrower, restricting blood flow to vital organs such as your brain and heart muscle, leading to high blood pressure. Additionally, chunks can break off and cause a heart attack or a stroke. And guess what? This build-up can start as early as your 20s,” say the Johns Hopkins guidelines.
Dr Singh says Indian guidelines are different for this precise reason. “Very low LDL levels can prevent much of cardio-vascular events. In extreme cases we should work towards the less than 30 mg/dL marker. And we need to start lipid-lowering drug therapies early on besides positive lifestyle changes for those at risk.”
What can be the preventive protocol?
“I come across many patients who have normal cholesterol levels but are still at a high risk of heart disease. This is because of many reasons – they are smokers, have a stressful life, live a sedentary lifestyle, are diabetic, have hypertension, have a family hory of heart disease. Usually in patients with less cholesterol, we look at all these risk factors together and then determine if we need to do further testing. This could include a CT scan of the heart, a treadmill test and a carotid ultrasound. People think that just because their cholesterol is normal, they are not at risk of heart disease. This is not correct. It is a misconception and even those who are fit but smoke excessively and drink too much need to get screened every six months. Those who are obese or don’t exercise regularly are definitely at risk. Even if their cholesterol levels are normal, they should religiously walk for 30 minutes, which can significantly reduce the risk of heart disease,” says Dr Manish Bansal, Director, Clinical and Preventive Cardiology, Heart Institute, Medanta Hospital, Gurgaon.
(*Name changed to protect identity)