High levels of "bad" cholesterol (LDL, also known as low‐density lipoprotein cholesterol) and low levels of "good" cholesterol (HDL, also known as high‐density lipoprotein cholesterol) are well-known indicators of the risk of future heart disease . There isn't any normal cholesterol number, however, that absolutely, positively tells you that you will or you will not have heart disease.
People who have high cholesterol may live to the age of 95 and never have heart disease or stroke, and people with low cholesterol may die at the age of 35 from a first heart attack. There is good evidence that for most people taking cholesterol lowering drugs in the statin class actually helps heart disease prevention (that is, avoiding a heart attack or sudden death). But so do other interventions.
Combining two major clinical trials
When two major clinical trials are considered together, different recommendations have strikingly different results:
- If the only thing your doctor recommends for you is a blood pressure lowering drug of the class known as calcium-channel blockers (for instance, verapamil), your risk of a future cardiovascular event actually goes up 33 percent. Recommending calcium channel blockers as a sole therapy was a common practice until about 2010.
- If the only thing your doctor recommends for you is a statin drug for lowering cholesterol and inflammation, your future risk of a cardiovascular event goes down 33 percent.
- If your doctor recommends lifestyle changes only, your risk of a future cardiovascular event goes down 43 percent. The two most commonly recommended lifestyle changes are smoking cessation and cholesterol lowing diet.
- If your doctor recommends a combination of lifestyle changes and a statin drug, your risk of a future cardiovascular event goes down 57 percent.
These numbers aren't absolute, either, but they give you a sense of the likely direction of results. The findings of long-accepted research (these studies were started in the 1980's and 1990's) tell us that with regard to heart disease prevention calcium channel blockers actually hurt. Statin drugs help. Lifestyle intervention such as cholesterol lowering diet and smoking cessation is even better. And a combination of statin medications and lifestyle changes is best. [2,3]
Just taking a statin drug might lower your overall risk of death from any cause in the next five years by 14 percent. A statin drug might lower your risk of a stroke in the next five years by 22 percent and your risk of a heart attack in the same period by 27 percent.  But combining statin drugs with lifestyle changes for lowering cholesterol naturally as well as medically, along with many other benefits, is even better.
What kinds of lifestyle changes improve your heart health?
- Medically speaking, there's nothing more beneficial to your heart health for the general population than a combination of controlling your blood pressure and lowering LDL .
- You may need medications to keep your blood pressure under control, but you can also do that by eating more vegetables and fruit and by limiting your consumption of salt and salty foods .
- Studies of the Mediterranean Diet, which emphasizes vegetables, fish, and olive oil, find up to 70 percent lower long-term rates of fatal heart attacks and stroke . In the short term, it lowers total cholesterol, lowers LDL cholesterol, and raises HDL cholesterol in people who don't have diabetes , and also in people who do have diabetes . It happens to be a cholesterol lowering diet, but it's also an anti-inflammatory diet.
Should you start the DASH diet or take up a Mediterranean Diet?
So should everybody start the DASH diet to limit salt and eat more vegetables, or take up a Mediterranean Diet with olive oil and nuts, and start measuring the blood pressure at home every day? Is lowering cholesterol naturally a must for everyone?
It's fine to eat more veggies and nuts, fish and olive oil. It's not a bad idea to avoid salt. It's a good idea to keep your blood pressure under control. However, simply lowering cholesterol naturally, with or without statin cholesterol lowering drugs, is not the secret to cardiovascular health for everybody. Here are the major exceptions:
- Just about everybody's total cholesterol levels go up after the age of 80. Using statin drugs to lower cholesterol levels that are "naturally" higher with age may actually increase the risk of death from cardiovascular disease.  If you are over 80, and you don't have disease called familial hypercholesterolemia, you may not need any kind of intervention even if your total cholesterol and LDL levels are higher than they used to be. Cholesterol lowering diets may not hurt, but they won't help, either.
- Testable genetics makes a huge difference in your risk of cardiovascular disease. If you have a variation of the APO-E gene called APOE e2, you may not need either to take drugs or to attempt lowering cholesterol naturally. But if you have a variation of the same gene called APOE e4, you may need to start monitoring your cholesterol carefully after the age of 45.  Your insurance may not pay for these tests, but they are available with a saliva test from 23 and Me.
Don't be afraid of statin drugs. Your doctor can always give you a very low dose. You might even wind up using a pill splitter to the right dose of a statin for you. But do avail yourself of genetic testing to know if you are someone who might especially benefit lowering cholesterol naturally or with statin cholesterol lowering drugs.