Not Too Late For a Flu Shot!

This year's flu is pretty nasty; there have been two deaths from it in California in the past 2-3 weeks.  The good news is that about 90% of the flu that we're seeing is prevented by this year's flu shot. These are still widely available at pharmacies and big-box retailers, so don't think it's too late to get one!

The Statins

"Statin" is shorthand for a class or type of medications that have been around since the late 1980's, which my daughter reminds me was a really long time ago.  It happens that their generic, chemical names all end in statin: pravastatin, lovastatin, simvastatin, atorvastatin, Brand-Xostatin... Hence, the name statins.

They were originally developed from naturally occurring chemicals, and only more recently (the mid-90's) synthetically created (Lipitor and Crestor).  Taking them reduces the production by your liver of LDL, or so-called "bad cholesterol".  The newer synthetic ones also reduce triglyceride production and increase HDL or "good cholesterol" production.

Perhaps more importantly, they turn out to have an unintended by benefical effect on reducing inflammation around cholesterol plaques and the blood vessel lining around them (the endothelium).  Lowering LDL production reduces the formation or enlargement of cholesterol plaques.  Raising HDL's actually reduces the number of cholesterol plaques in your arteries.  The statin-induced decrease in inflammation prevents cholesterol plaques from rupturing and actually causing heart attacks or strokes.

On average, you can lower LDL's through diet improvement by 7-14%, and raise HDL's through aerobic exercise by 2-3%.  I have certainly seen some patients do way better, but it's safe to say they added motivation to a lifestyle where there was lots of room for improvement.  Overall, this means most of the problems with cholesterol levels are genetic and tough to control.

As mentioned in the previous posts not everyone needs to be on a statin, and statins are not a substitute for a diet of modest amounts of meat, whole grain carbs, and plenty of fruits and vegetables and also putting in 150 minutes of cardio a week.

At the same time, there are a lot of myths and misunderstandings about statins.  I have already explained how statins work. The rest of this posting is to address what they can do for you, and their side effects (both real and putative).

Downsides:

• Can they hurt your liver? No.  This has been shown several times over the years.  Why do warnings still appear on the materials you get with the medications? Warnings are never removed.
• Can they cause severe muscle damage? Yes, but it's rare at well under 2% of the time.  (By comparison, your odds of "dying on the table" during a routine surgery is also less than 2%.) One study demonstrated occurence at a rate between 8-25 times in 10,000,000. That's mighty rare.
• Can they cause obnoxious muscle or joint pains that go away when you stop taking the statin? No?  We can't tell.  When you take a few thousand people and give half of them a statin and the other half a placebo (in which none know for sure which they are getting), 8-9% of the people on statin report this side-effect.  Thing is, exactly 8-9% of the people on the placebo report the side-effect, too.  So, either this is a side-effect that occurs in 8-9% of people, or in none.  It does demonstrate the "nocebo" effect: people are likely to experience a side-effect if they expect to.
• Otherwise, the most common side-effect is excessive flatulence (farting more than usual).  This may occur as frequently as 15% of the time, though I've never had a patient (or their spouse) comment on it. Hmm....

Upsides:

• Reduce your risk of ever having a cardiac arrest, heart attack, or stoke by nearly half.
• Also, reduce risk of Alzheimer's disease and colon cancer. (Technically these are side-effects, but we like them.)

The upshot?  Is it possible to have side-effects to a statin? Yes. Everything is possible.  However, the benefit significantly outweighs the down side. Risk of bad stuff: no higher than 8%, probably less. Risk of good stuff: 40-50%. 

Frankly, I don't prescribe medications lightly. Statins don't replace healthy eating and exercise, and not smoking.  But if you need one, taking one is a safe and effective way to prevent heart attacks and strokes.

More on the subject of Healthy, Balanced Diet

There has been a lot in the news about healthy diets, especially about trans fats and processed or red meats.  This is relevant to the earlier post on cholesterols.

It turns out that eating foods that are high in cholesterol doesn't necessarily translate to high cholesterol levels.  For example, eating eggs turns out to be a very high-quality source of protein that is relatively inexpensive and widely available and doesn't affect cholesterol levels. (Yes, we were wrong about that.  I think there was even a Simpsons episode on that...)  What's probably more the issue is the use of trans fats in mass-produced foods that increases risk of heart attacks and strokes.  So yes; it turns out eating butter instead of margarine is not only better tasting it's also healthier.  Just bear in mind that the reason Paula Dean is diabetic is not because she cooks with butter, it's because she cooks with a lot of butter which is a lot of calories.

The announcement by the World Health Organization last week that processed meats (smoked, pickled, salted or otherwise preserved in ways that were used before refrigeration) can cause colon cancer, and that red meats may also do so has been known for about 40 years.  If you want to stop eating them in favor of fish and chicken, or want to eat a completely vegan diet that's fine.  If you want to simply eat less red meat and more whole grains, fruits and vegetables that's also fine.  Like eating eggs, or butter the amount is key.  It doesn't have to be all or nothing; balance is the important part; just like the rest of life : ).

As an addendum for  hunters: venison, elk and boar are red meats.  However, by comparison to beef and pork they are much leaner and lower in carbs, and thus are generally healthier.  (Native Americans didn't get diabetes until after they were forced onto reservations.)  Do remember that "mad cow disease" or Bovine Spongiform Encephalopathy has been found in elk.  Stay away from the brain and spinal cord, or better yet have your elk professionally butchered.

A New Look at Cholesterol

Doctors actually have real interest in knowing whether or not what we are doing works.

For example, we know that managing your cholesterol reduces your odds of cardiac arrest, heart attack and stroke.  We know this based on a scientific understanding of cholesterol, and also by the fact that we have reduced the occurrence of heart attack and stroke by about half over the past 20 years, which is pretty fantastic.  We treat heart attack and stroke more effectively than in the past, but it's certainly better to just not have one at all!

Also, we know that diet has a  part to play in helping with your cholesterol and have been making recommendations about diet and not just medications for years.

On the other hand, when we re-examine things  and come up with better or different ideas we look closely at these ideas and then come to a consensus as to what to do with the new information.  This would be called science.

In that vein (no pun intended, here), two things within the last year or two have come to light and have become widely accepted about cholesterols.  One has to do with when to use drugs for high cholesterol, and the other is about diet.

Since the 1990's we have seen that cholesterol lowering through dietary modification, the use of prescription drugs (the so-called 'statins) or both results in preventing cardiac arrests, heart attacks and strokes.

The role of statins has been around your LDL (low-density lipoproteins; the so-called "bad cholesterol"). Specifically, we have seen that you are at 40-44% lower risk of a heart attack or stroke if your LDL is less than 160, under 130 if you also smoke or have high blood pressure, under 100 if you have diabetes, and under 70 if you have already had a heart attack and we are trying to prevent a second one.

The American Heart Association and the American College of Cardiology (a professional organization of U.S. heart specialists) periodically examine efforts to prevent heart attacks and strokes; in other words, is what we're doing working, and can we do better?

Towards the end of 2013, they recommended a really sweeping change in how doctors should use statins (a widely used type of cholesterol lowering medicine since the 1980's). They basically took how we already know statins work to prevent heart attacks and strokes and applied them to already existing ways to determine a person's risk of actually having one over the next ten years in an effort to figure out whether a patient would actually benefit from being on a statin at all, and if so what kind and how much.

These recommendations were widely debated, re-tested and verified, and the bottom line is that they are regarded as valid and beneficial and over the past half a year or so are being put into practice.

So instead of looking purely at a static LDL level, we now use age, gender, blood pressure, your cholesterol results and whether or not you smoke or take blood pressure pills to calculate your risk of having a heart attack or stroke in the next ten years.

If this risk is under 5%, there is no need of using a statin as you are already at low risk and adding a statin isn't going to improve on this.  At 5-7.5%, a statin dose sufficient to lower cholesterol by about 25% would reduce risk to less than 5%.  At over 7.5%, that's quite high and using a statin capable of lowering cholesterol by about 50% would also cut your heart attack or stroke risk by half.

This is not to take away from the value of eating a healthy balanced diet, exercising regularly and not smoking.  It is also not a way to put more people on statins.  In fact, this new way of looking at cholesterol test results plus personalized information reduces the overall number of folks needing statins.  In other words, the idea is not to use more statins, it's to use them smarter.

All you need to calculate your own risk is your systolic blood pressure (the first, higher number) and your lab results.  Feel free to check it out using the above link, or this free iPhone app from the American College of Cardiology (I'm sure there's an Android version, too).   There's a lot of information in the app and in plain English.  It also is interesting to tweak the numbers a bit to see how much lower your risk would be if you lowered you blood pressure or stopped smoking!