Recently the skeptical cardiologist was asked by Ilene, a reader with an HDL almost as high as her LDL and a history of branch retinal vein occlusion (BRVO) whether she should take the statin her cardiologist had prescribed.
I enjoy reading your articles and would appreciate your opinion on my situation. I recently took a lipid panel blood test: total cholesterol: 244 HDL:112 LDL:121 VLDL:11 CRP: 1.77 Triglycerides: 57. Also my Cardiac Agatston score is 21.
I had a Branch Retinol Vein Occlusion a year ago in my left eye (it’s healing beautifully) and as a precaution am now taking Amlodipine 5mg daily (my blood pressure was never too high to begin with) along with a daily baby aspirin.I am otherwise a healthy 72 year old woman, exercise and eat healthy.My regular doctor (Integrative MD) says my cholesterol ratio is wonderful….my cardiologist wants me to take a statin (Atorvastatin) in a low dose. The ONLY med I take is Amlodipine and I am not one to be taking a plethora of meds for the rest of my life (unless “absolutely” necessary. What is your suggestion…take a statin or not.
I enjoy reading your articles and would appreciate your opinion on my situation. I recently took a lipid panel blood test: total cholesterol: 244 HDL:112 LDL:121 VLDL:11 CRP: 1.77 Triglycerides: 57. Also my Cardiac Agatston score is 21.While I can’t provide medical advice to Ilene specifically it is worthwhile to ponder the general aspects of her case and how I would approach it as it likely applies to thousands of other patients including many of my own.
In my mind there are two questions here: 1) Should Ilene and patients like her take a statin to prevent future heart attacks and strokes and 2) Do statins effect the Branch Retinal Vein Occlusion (BRVO)?
Although I’m not a fan of integrative or functional medicine Ilene’s integrative MD is correct in saying that her ratio of total cholesterol to HDL cholesterol is wonderful. Perhaps that high HDL is protecting her from a build-up of atherosclerotic plaque.
On the other hand, Ilene tells me that “My father did have a heart attack in his 60’s”. Perhaps she inherited something from him that puts her in a higher than average risk category.
With the information from the CAC we don’t have to guess about the influence of the high HDL and the family history of CAD. Her score is at the 48th percentile, slightly below average for white women her age, thus it would appear she is not destined for her father’s fate.
Frequent readers of skepcard (especially my posts on statin fence sitters) will know I plug all these numbers (preferably with the calcium score available) into the MESA coronary calcium risk calculator
In this case, the CAC score does not significantly alter our risk estimate as it is so close to the average for her age
Even if we count her as having hypertension because she is on the amlodipine her 10 year risk of heart attack and stroke is low at 3.2%.
Guidelines don’t recommend statin treatment unless risk is >7.5%.
Also, note that I answered yes to “Family history heart disease” but most studies generally only consider this a risk factor if father had heart attack prior to age 55 years. If we make that a no the risk drops to <3%.
Now that we’ve answered Ilene’s real question let’s see if the BRVO warrants statin therapy.
Branch Retinal Vein Occlusion
BRVO is the blockage of a vein from the retina and the second most
common cause of vision loss from retinal vascular disease, following diabetic retinopathy. It typically results in the painless loss of vision in one portion of one eye due to hemorrhage and edema in the retina.
common cause of vision loss from retinal vascular disease, following diabetic retinopathy. It typically results in the painless loss of vision in one portion of one eye due to hemorrhage and edema in the retina.
A reasonable summary of BRVO provided by the American Academy of Ophthalmology can be found here.
BRVO is not clearly related to atherosclerosis or hyperlipidemia and there is no evidence that taking a statin would prevent recurrence or help the condition.
The leading theory for what causes BRVO is that the more delicate and distensible retinal veins are squished or compressed at points where the stiffer and thicker retinal arteries cross them. Up to Date notes:
Whereas branch retinal vein occlusion (BRVO) appears to be related to compression of the branch vein by retinal arterioles at the arteriovenous crossing points, central retinal vein occlusion (CRVO) is usually associated with primary thrombus formation.
Although BRVO is more common in patients with hypertension and atherosclerosis it is not clear that one causes the other or that treatment of hypertension or atherosclerosis diminishes the risk of BRVO. So statins are not recommended.
More Questions
Every patient case for me leads to more questions, more investigations and more knowledge. Here are some questions that occurred to me from ilene’s case.
-Why would someone with no symptoms and no heart problems be seeing a cardiologist?
(“I started seeing a cardiologist just to make sure all systems were “go” and stayed that way!… we take care of our cars so why not my body. )
I kind of like this answer and I definitely see lots of patients with that philosophy but if we extrapolate the car analogy: going to a cardiologist would be like taking your car to a mechanic who only works on engines or perhaps one specific part of the engine (help me out here people who know about cars.)
-Why was Ilene unwilling to take a statin? (I pretty much know the answer to this (see here) for most patients.
‘m just afraid of the horrible muscle related side effects of statin drugs…and that’s why I’m taking Berberine 500mg twice a day.
Yep. I feel a post abut Berberine may be in the works!
-Finally, should a 72 year old with a CAC score of 21 and BRVO be taking a baby aspirin?
I’ve generally advocated aspirin in primary prevention for scores >100 so wouldn’t advise it for prevention of cardiovascular events in this situation.
In addition, I have seen nothing in the literature that recommends aspirin for BRVO. These two BRVO experts do not recommend either aspirin or anticoagulants.
Proretinally Yours,
-ACP
N.B. If you have a blockage of the the artery that supplies blood to the retina or a branch retinal artery occlusion ( BRAO)
you might benefit from a statin as this is often caused by a clot or plaque flying out of the heart or the carotid artery.
4 thoughts on “Ilene Has High Cholesterol With A "Wonderful Ratio" And A Branch Retinal Vein Occlusion: Should She Take A Statin?”
Great post as ever. Can I draw you out on the threshold for aspirin based on CAC. What evidence is it that you feel still supports the use of CCS >100 as a threshold. In the ASPREE study it could reasonably be expected that 1/3 of women and 2/3 of men would have had CAC score above this level (based on the median age and MESA data).
Best Regards
I think I’ve referenced this in a post but I found this study useful….https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4412344/
Results were stratified by a 10% 10-year CHD Framingham Risk Score (FRS). Individuals with CAC ≥ 100 had an estimated net benefit with aspirin regardless of their traditional risk status (estimated NNT5 of 173 for individuals <10% FRS and 92 for individuals ≥ 10% FRS, estimated NNH5 of 442 for a major bleed). Conversely, individuals with zero CAC had unfavorable estimations (estimated NNT5 of 2,036 for individuals <10% FRS and 808 for individuals ≥ 10% FRS, estimated NNH5 of 442 for a major bleed). Gender specific and age-stratified analyses showed similar results.
Interesting, in that I have always had very high HDL, but for me it has been anything but protective. I have now had 4 heart attacks & am in heart failure, trying to find a way to prevent any more from happening…
Evelyn,
As you have discovered not all high HDL is protecctive. A recent study suggested that very high HDL levels actually may add to risk. That’s why I’m a big advocate of assessing for subclinical atherosclerosis rather than assuming a high HDL is a good thing for an individual patient