I’ve tried a couple of statins, and the side effects — particularly muscle pain — always knock me off them. The problem is my cholesterol is almost 400, and I’m scared I’ll have a heart attack before I’m 45, like my dad did. What do you suggest I do? 

Start by getting the genetic test for familial high cholesterol, also called familial hypercholesterolemia (FH); it affects about 1 in 500 folks. It happens because a genetic mutation makes your body unable to clear lousy LDL cholesterol from your bloodstream. In adults it’s diagnosed when there’s a family history of premature heart disease and lousy LDL cholesterol is 190mg/dL or higher (in kids it’s 160 and up). Genetic testing is recommended to confirm a diagnosis of FH if there’s some doubt about the cause of elevated LDL. Without effective treatment, guys with FH have a 50 per cent chance of having a heart attack before age 50; gals with FH have a 30 per cent chance.

Statins normally would be your first line of defence, and for many people they’re lifesavers, but for you, their side effects are a deal breaker. There are other cholesterol-lowering medications, such as niacin and ezetimibe (used singly they lower LDL 19 per cent to 32 per cent) that you might tolerate, but neither seems to substantially decrease heart attack risk.

If you do have FH, there’s a treatment called apheresis, in which blood plasma, removed from your body, is passed through filters to remove extra LDL-cholesterol, and then returned to your body; this is a very difficult treatment regimen.

But here’s better news: Researchers have discovered a once-a-month injection of a monoclonal antibody called evolocumab helps your body get rid of LDL cholesterol. LDL levels fall by about 60 per cent — without taking a statin or another anti-cholesterol medication. (For folks with very high LDL that is not familial this antibody reduces levels by up to 75 per cent.)

Although this drug won’t hit the market for a few years, for now you can work with your doc on a new treatment plan that improves your meds, nutrition, increases physical activity safely and reduces stress.