A Brilliant Post, IMHO. Thank you Dr Axel F. Sigurdsson MD, PhD, FACC.
This ‘Doc’s Opinion’ article is linked here. Also read its connected comments for further insights.
The risk of heart disease has been associated with countless different things. Smoking, diabetes, high blood pressure, overweight, obesity, sitting and watching TV, eating too much fat, eating too much sugar, not eating certain fats, eating meat, not eating fish, eating too much animal fat, eating cholesterol, eating saturated fat, eating trans fats, high blood cholesterol, high LDL-cholesterol, inflammation, family history of heart disease…. The list is long. How on earth can we avoid being hit by this dreadful disease, the most common cause of death and disability worldwide?
The risk of heart disease increases with age. So, if we become old enough, we will probably have heart disease sooner or later, and most likely die from it. But that is not necessarily a bad thing. We all have to die from something. Dying from something else is not a goal by itself. So maybe we would be more accurate if, instead of aiming at preventing heart disease, our goal was to delay the onset of heart disease. However, defining our goal is probably less important than defining the methods to achieve it.
A huge number of healthy adults will have heart disease in the next ten years. Many will be treated with drugs, some will have angioplasty and stents, and some will have open heart surgery. Many will die from the disease. A substantial number will be left with severe disability. Many will not be able to work, and many will not enjoy the quality of life they had before the disease hit them. So, I presume we all agree that delaying the onset of heart disease is a worthwhile target.
Who should worry about getting heart disease? Probably everybody. But, who should worry the most? Who is most likely to be struck by heart disease in the next few years? This is where it comes to the so-called risk factors. If yo have many risk factors, the risk of having a heart attack or stroke becomes higher. The strongest risk factors are smoking, diabetes, high blood pressure, high levels of LDL-cholesterol, low levels of HDL-cholesterol, overweight or obesity, and family history of premature coronary artery disease. If you don´t have any risk factors, your aim should be to avoid them at all costs. But, if you have some of these risk factors, what can you do?
Let´s assume you are a responsible person (you probably are because you are reading my blog), and you want to do everything you can to delay the onset of heart disease. Maybe your father had a heart attack in his fifties. Maybe you have gained a bit of weight and maybe your cholesterol level is a bit to high. So, you decide it´s time to have a chat with your general practitioner Dr. Oxenhaler, the family doctor. Last year he put you on a drug to lower your blood pressure. This time, you are better prepared for your visit because you have been reading my blog.
You are sitting in front of Dr. Oxenhaler in his office. He just finished measuring your blood pressure and now he is watching your blood work on his computer screen. This is how the conversation might evolve.
‘Is there a specific reason you decided to come to see me. Have you been having chest pain or discomfort of any kind?’
‘No Doctor Oxenhaler. I was just worried. I´ve been reading lots of stuff about heart disease on the internet. I was wondering what I should do avoid having heart attack.’
‘Well, I guess you should be a little bit worried, but I´m glad you care. That´s the first step. Your blood pressure is fine, thanks to the medication I prescribed for you last year. However, your cholesterol is 277 mg/dl (6.9 mmol/L), that´s way to high.’
‘How about my LDL cholesterol?’
Doctor Oxenhaler watches you closely, his glasses gliding down on his nose. He takes a deep breath.
‘I see you´ve been reading. That´s good. Education is the key to a better health. Your LDL cholesterol is 182 mg/dL (4.7 mmol/L), that´s also way to high. HDL-C, the good cholesterol is 40 mg/dL (1.0 mmol/L) which is to low. Considering your family history and your history of high blood pressure, the risk of having coronary heart disease is quite high. By using the Framingham risk calculator I can see that your risk of having a heart attack in the next ten years is about 17 percent.’
You feel a little numb, like the blood is draining from your face. Doctor Oxenhaler notices your paleness and becomes a bit more sympathetic.
‘Don´t be scared though. We can take care of this. Treatment is available. By putting you on a cholesterol lowering drug, we can lower your risk substantially. Your cholesterol will go down and so will LDL-cholesterol. Your risk of heart attack will be much less’.
‘But I read that the effects of statin drugs is very small when they´re used for prevention in people who don’t have heart disease’.
‘No. that´s a misinterpretation. The risk reduction in the clinical trials is about 30 percent among high risk individuals, which in my mind is quite substantial.’
‘You´re talking about relative reduction then Dr. Oxenhaler, aren´t you?´
There is a momentary pause. You catch a glimpse of surprise in his eyes. He looks at his watch and then back at you, a faint smile on his lips.
‘Yes, relative reduction, that´s correct’, he says.
‘I´ve read that statins have lots of side effects as well.’
‘Side effects are very uncommon. A small number of of people have muscle pain, but it´s rare. Most people do not have any problems with cholesterol lowering drugs.’
‘I read that some people have memory loss.’
He looks surprised.
‘I don´t recall any of my patients complaining of memory loss from statins.’
Now you can´t help wondering whether Doctor Oxenhaler is on a statin drug. You dismiss the thought immediately. You have to keep focus.
‘I´ve heard there is more risk of diabetes if you take statins.’
He loosens his tie a bit, he has stopped smiling. You´re aware that you´re using up a lot of his time. There are more patients waiting for him.
‘Let me just tell you that the benefits of statins definitively outweigh the risks’, says Doctor Oxenhaler
But you´re not giving up.
‘Isn´t there something I can do by my self, change may diet or exercise more?, you ask.
‘Diet and exercise is fine. Cut down on fats, especially saturated fat and don´t eat too much cholesterol. That´s helpful. But it won´t replace statin treatment when it comes to reducing your risk.’
‘I heard about a study published last week in The New England Journal of Medicine showing that a Mediterranean diet could lower the risk of heart attack and stroke if you have risk factors like me’
‘You´re right indeed, but the effect is very small. Besides, diets are usually hard to stick with.’
‘I read that the relative risk reduction was about 30 percent on the Mediterranean diet compared to a low fat diet. Isn´t that about the same effect that statins have in a similar population?’ Could a Mediterranean diet be an alternative to statin therapy?
Doctor Oxenhaler does not answer right away. He stares at the computer screen.
‘Very well, why don´t you try the Mediterranean diet for six months and then come visit me again. We´ll measure your cholesterol and decide what to do. If it´s still high I definitively recommend statin treatment to cut your risk´, he says eventually, still watching the computer screen.
‘Isn´t it possible that the diet is helpful, although my cholesterol stays the same?’
Now he is looking at you again, more seriously than before. You can´t really tell whether he is annoyed or not.
‘If we are to succeed in lowering your risk of heart disease, we must lower your LDL-cholesterol. That´s a fact.’
‘But, I just read about the Women´s Health Initiative where reducing the intake of fat lowered cholesterol, but did not cut the risk of heart disease’.
Now he is up on his feet and offering his hand. He shakes his head in disbelief, but he is smiling again.
‘Please come back to see me in six months. Good luck with the Mediterranean diet. Go easy on the wine though. And for God´s sake don´t believe everything you read on the internet…..‘
With very due respect to my GP, who does a wonderful job and does not press his beliefs strongly on me, when offered some written references about contrary theories (cardio related such as this article), he responded “I don’t read that sort of material, I am guided by the cardiologist recommendations”.
In the case of my cardiologist, whom I also seriously respect, I have been “soft”, but he knows my aversion to statins and has also been respectful about my reluctance, to a degree.
- ‘The great cholesterol myth’ (foxnews.com)
- Doubts Emerge on the Value of Very Low Cholesterol Levels (scientificamerican.com)
- Side-Effects Cause A Quarter Of Heart Patients To Stop Treatment In The HPS2-THRIVE Trial (medicalnewstoday.com)
- Kick your cholesterol panel in the butt! (sott.net)