Lowering cholesterol is highly effective in lowering heart disease and stroke risk. Elevated cholesterol is an important risk factor in the development of heart disease. When measuring cholesterol in the blood, we not only assess total levels of this waxy, fat-like substance but also the low density lipoprotein (LDL) and high-density lipoprotein (HDL), cholesterol and triglycerides.

The most important risk factor for heart disease is having high LDL and low HDL cholesterol. Total cholesterol of greater than 200 and an LDL greater than 130 are the upper limits of "normal." The best measure of heart disease risk is the ratio of the LDL divided by the HDL. A value greater than 5 is cause for great concern.

In assessing the need for treatment, these measurements are more important than your total cholesterol. For example, someone with a total cholesterol reading of 240 (that would be considered quite high) but who has an HDL of 100 and an LDL of 110 is considered to be at low risk, and treatment is not warranted.

The first approach to lowering cholesterol is diet and exercise. A diet high in fiber and rich in omega-3 fatty acids and the monounsaturated fats found in olive and canola oil, fish, nuts and certain vegetables can significantly reduce cholesterol levels. Add to this appropriate weight loss and exercise, and risk of vascular disease can be reduced dramatically.

For most people with abnormal cholesterol, diet and exercise alone are inadequate to reach target levels.

For those who have no vascular disease, the target LDL should be less than 100 and the LDL-to-HDL ratio less than 3. For those who have a history of heart disease or stroke, a target LDL should be less than 70, and the ratio should be as low as possible. Unless there is a major contraindication, their initial treatment should include a generic statin (such as pravastatin, lovastatin, simvastatin), most of which cost less than $12 for a three-month supply. And recently Lipitor (atorvastatin), the most popular statin, has become available as a generic drug.

Most patients tolerate statins, which means they can take these drugs without damaging side effects, and with dose adjustment, most people are able to achieve their target levels for cholesterol. A survey of 27 studies published in the journal Lancet showed that statin treatment in normal individuals with moderately elevated cholesterol significantly reduced the risk of heart attacks and strokes. The results were so compelling that experts have suggested that everyone over 50 should be treated with the drug. Today in Britain and most of Europe, statins are available over the counter.

In the past few years, much attention has focused on the development of medications to raise the good HDL cholesterol (its levels are not affected by statin treatment). The most promising approach is the use of large doses of Vitamin B-1 or niacin; this raises the HDL cholesterol while simultaneously lowering elevated triglycerides, which also can increase the risk of heart disease. Many people cannot tolerate niacin because it causes intense flushing and burning of the skin. To overcome this, niacin has been combined with laropiprant, an anti-flushing agent. This "drug" is marketed as Niaspan.

Recently, the results of a large clinical trial that studied the combined effects of Lipitor and Niaspan on reducing the risk of heart attacks and strokes was presented at the 2013 meeting of the American College of Cardiology. There was great hope that the combination would be a highly effective strategy at eradicating heart disease as the major cause of death in America. The study examined 25,673 patients, and, sadly, the addition of Niaspan to Lipitor did not reduce the risk of heart attack or stroke.

And the unacceptably high level of side effects, which included a 25 percent increased risk of diabetes, infections and bleeding, raised grave concern. This study has seriously questioned whether niacin should ever be used. Readily available over the counter, non-flushing niacin is taken by many and may cause more harm than good.

While a heart-healthy lifestyle is most important, medications appear to be highly effective approaches to prevention. While statins still remain the cornerstone of therapy, I hope future research will develop novel approaches to further reduce the overwhelming burden of heart disease and stroke, which reduce the quality and quantity of life for so many.

Dr. David Lipschitz is the author of the book "Breaking the Rules of Aging." To find out more about Dr. David Lipschitz and read features by other Creators Syndicate writers and cartoonists, visit the Creators Syndicate Web page at www.creators.com. More information is available at: DrDavidHealth.com.