Rethinking Cholesterol and Heart Disease Risk with Cardiologist Michael Ozner, MD

You might think cholesterol alone is the key indicator of a healthy heart, but it’s not the “root” cause.

Learn how atherogenic lipoproteins become the deciding factor that leads to heart disease. Learn how to reduce your heart disease risk and the importance of omega-3 fatty acids.

Rethinking Heart Disease Risk and Cholesterol

What’s the most important factor in heart disease?

Cholesterol, right?

Not so fast, cautions cardiologist Michael Ozner, MD. “I think it’s very important that we understand the root cause of heart attacks.”

“It’s not cholesterol per se but, rather, these particles which we call atherogenic lipoproteins that carry cholesterol and triglycerides. Cholesterol actually serves a worthwhile purpose. It’s required for cell membranes, for steroid hormone development, for bile, and other things, and triglycerides are useful as energy source. We need them, and they can’t travel by themselves. They need to be carried.”

Dr. Ozner, who is the medical director of Wellness and Prevention at Baptist Health South Florida, likens lipoproteins to vehicles and cholesterol and triglyceride molecules to passengers. Traffic jams are caused not by too many passengers, but by too many vehicles which, when they have nowhere to go, take the exit ramp into the arterial wall where they can become trapped, modified, and oxidized. This process initiates the disease known as atherosclerosis. Atherosclerotic plaque is a collection of lipoproteins with their cholesterol and triglyceride cargo. Rupture of these plaques can lead to heart attack and stroke.1

Cholesterol and Atherogenic Lipoproteins

Understanding heart disease risk:

Apolipoprotein B (ApoB) is a component of some of the most atherogenic lipoproteins, including low-density lipoprotein (LDL), very low-density lipoprotein (VLDL), and intermediate-density lipoprotein (IDL) particles. Apolipoprotein A1 (ApoA1), on the other hand, is primarily associated with high-density lipoprotein (HDL) particles and is potentially helpful. Levels of ApoB and its ratio to ApoA1 have a stronger association with cardiovascular disease risk than the better-known lipoprotein cholesterol fractions.2 These factors can be evaluated with blood tests.

Heart Attack Misconceptions

While LDL cholesterol has long been considered the standard test to assess cardiovascular risk, LDL is not the root cause of atherosclerosis, according to Dr. Ozner. Elevated LDL-cholesterol levels contribute to risk but don’t always correlate with more important ApoB levels.

Individuals who are overweight with insulin resistance may have low LDL-cholesterol levels and think they’re not at risk of experiencing a cardiovascular event.3 A classic example of this phenomenon was the sudden death from heart attack of journalist Tim Russert: although doctors reported his LDL-cholesterol level was normal, an autopsy showed that he had advanced coronary artery disease.4

Heart Disease, Omega-3 Fatty Acids

Fortunately, most heart attack deaths are preventable. The importance of a healthy eating pattern, such as the Mediterranean diet, can’t be overemphasized.5 In contrast with the atherosclerosis-prone Western world is the Tsimane tribe of South America, who subsist by hunting, gathering, farming, and fishing. Although a high percentage of Tsimane have intestinal parasites triggering systemic inflammation, this tribe has one of the lowest levels of coronary artery disease of any population on record.6 Among many protective factors, the tribe’s intake of omega-3 fatty acids from the fish they harvest could be one of the most important. Consuming a high amount of marine omega-3 fatty acids, which include EPA and DHA, promotes cardiometabolic health; helps maintain normal triglyceride levels, heart rhythm, and blood pressure; and lowers inflammation.7-9

In one randomized, controlled trial, EPA combined with a statin drug was associated with greater regression of coronary plaque than drug therapy alone.10 This suggests that omega-3 supplementation may add to the reduction in risk of a cardiovascular event for those undergoing statin therapy. Assessment of omega-3 blood levels using the Omega-3 Index test can help guide appropriate omega-3 fatty acid intake.11

“For half a century, a high level of total cholesterol or low-density-lipoprotein cholesterol has been considered to be the major cause of atherosclerosis and cardiovascular disease (CVD), and statin treatment has been widely promoted for cardiovascular prevention,” noted a worldwide group of physicians in a recent review. “In our analysis of three major reviews that claim the cholesterol hypothesis is indisputable and that statin treatment is an effective and safe way to lower the risk of CVD, we have found that their statements are invalid, compromised by misleading statistics, by exclusion of unsuccessful trials, by minimizing the side effects of cholesterol lowering, and by ignoring contradictory observations from independent investigators.”12

Elevated LDL Cholesterol

Why this is not the sole factor for determining heart disease risk:

Elevated LDL cholesterol is one of many factors that have been associated with cardiovascular disease but according to many experts in the field, it’s not the most important one. The good news is that cardiovascular disease is largely preventable with a combination of lifestyle factors that may protect against a number of other diseases prevalent in our era.

Intrigued by what Dr. Ozner has to say? Visit and listen to the Live Foreverish podcast of Life Extension®’s Dr. Michael Smith, with featured guest Michael Ozner, MD, who is medical director, Wellness and Prevention, Baptist Health South Florida, as they discuss “Cholesterol and Heart Disease Risk.”

If you like what you hear, please take a moment to give Live Foreverish a 5-star rating on iTunes!


  1. Linton MF, Yancey PG, Davies SS, et al. The Role of Lipids and Lipoproteins in Atherosclerosis. [Updated 2015 Dec 24]. In: De Groot LJ, Chrousos G, Dungan K, et al., editors. Endotext [Internet]. South Dartmouth (MA):, Inc.; 2000-. Available from:
  2. Sandhu PK et al. J Appl Lab Med. 2016 Sep;1(2):214-29.
  3. Lim Y et al. Endocrinol Metab (Seoul). 2015 Jun;30(2):208-15.
  4. Lavie CJ et al. Ochsner J. 2008 fall;8(3):108-13.
  5. Torres N et al. Arch Med Res. 2015 Jul;46(5):408-26.
  6. Kaplan H et al. Lancet. 2017 Apr 29;389(10080):1730-1739.
  7. Mozaffarian D, Wu JH. Am J Coll Cardiol. 2011 Nov;58(20):2047-67.
  8. Bird JK et al. Nutrients. 2018 Jun;10(6):pii:E775.
  9. Arca M et al. Nutr Metab Cardiovasc Dis. 2018 Mar;28(3):197-205.
  10. Watanabe T et al. J Cardiol. 2017 Dec;70(6):537-544.
  11. von Schacky. Nutrients. 2014 Feb;6(2):799-814.
  12. Ravnskov U et al. Expert Rev Clin Pharmacol. 2018 Sep 10.


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