Should I Take Aspirin To Prevent Stroke or Heart Attack?

 

Aspirin is a unique drug, the prototypical  two-edged sword of pharmaceuticals.  It has the capability of stopping platelets, the sticky elements in our blood, from forming clots that cause strokes and heart attacks when arterial plaques rupture, but it increases the risk of serious bleeding into the brain or from the GI tract. Despite these powerful properties, aspirin is available over the counter and is very cheap, thus anyone can take it in any dosage they want. 

Who Should Take Aspirin?

For the last five years I’ve been advising my patients who have no evidence of atherosclerotic vascular disease against taking aspirin to prevent heart attack and stroke. Several comprehensive reviews of all the randomized trials of aspirin had concluded by 2011 that

The current totality of evidence provides only modest support for a benefit of aspirin in patients without clinical cardiovascular disease, which is offset by its risk. For every 1,000 subjects treated with aspirin over a 5-year period, aspirin would prevent 2.9 MCE and cause 2.8 major bleeds.

(MCE=major cardiovascular events, e.g. stroke, heart attack, death from cardiovascular disease)

Dr. Oz, on the other hand, came to St. Louis in 2011 to have  lunch with five hundred women and advised them all to take a baby aspirin daily (and fish oil, which is not indicated for primary prevention as I have discussed here). When I saw these women subsequently in my office I had to spend a fair amount of our visit explaining why they didn’t need to take aspirin and fish oil.

After reviewing available data, the FDA this week issued a statement recommending against aspirin use for the prevention of a first heart attack or stroke in patients with no history of cardiovascular disease (i.e. for primary prevention). The FDA pointed out that aspirin use is associated with “serious risks,” including increased risk of bleeding in the stomach and brain. As for secondary prevention for people with cardiovascular disease or those who have had a previous heart attack or stroke (secondary prevention), the available evidence continues to support aspirin use.

Subclinical Atherosclerosis and Aspirin usage

As I’ve discussed previously, however, many individuals who have not had a stroke or heart attack are walking around with a substantial burden of atherosclerosis in their arteries. Fatty plaques can become quite advanced in the arteries to the brain and heart before they obstruct blood flow and cause symptoms. In such individuals with subclinical atherosclerosis aspirin is going to be much more beneficial.

 

Guided Use of Aspirin

zerilloplaque
Large, complex atherosclerotic plaque in the carotid artery found by vascular screening in an individual with no history of stroke, heart attack, or vascular disease. This patient will definitely benefit from daily aspirin to prevent stroke or heart attack
We have the tools available to look for atherosclerotic plaques before they rupture and cause heart attacks or stroke. Ultrasound screening of the carotid artery, as I discussed here, is one such tool: vascular screening is an accurate, harmless and painless way to assess for subclinical atherosclerosis.

In my practice, the answer to the question of who should or should not take aspirin is based on whether my patient has or does not have significant atherosclerosis. If they have had a clinical event due to atherosclerotic cardiovascular disease (stroke, heart attack, coronary stent, coronary bypass surgery, documented blocked arteries to the legs) I recommend they take one 81 milligram (baby) uncoated aspirin daily. If they have not had a clinical event but I have documented by either

  • vascular screening (significant carotid plaque)
  • coronary calcium score (high score (cut-off is debatable, more on this in a subsequent post)
  • Incidentally discovered plaque in the aorta or peripheral arteries (found by CT or ultrasound done for other reasons)

then I recommend a daily baby aspirin (assuming no high risk of bleeding).

There are no randomized trials testing this approach but in the next few years several large aspirin trials will be completed and hopefully we will get a better understanding of who benefits most from aspirin for primary prevention.

Until then remember that aspirin is a powerful drug with potential for good and bad effects on your body. Only take it if you and your health care provider have decided the benefits outweigh the risks after careful consideration of your particular situation.

Moogfest, the Z-pak, the QT interval and Sudden Cardiac Death


kraftwerk
The skeptical cardiologist was planning on attending Moogfest 2014 in Asheville, North Carolina last weekend. I was going with the old friend and life coach of the skeptical cardiologist (OFLCSC) and planned on taking in electronic and synthesizer legends like Kraftwerk and Keith Emerson, riding bikes and drinking lots of craft beer. Unfortunately, a very bad upper respiratory infection took hold of me, progressing to what felt like a pneumonia (shaking chills, fever, coughing up dark, thick sputum, rattling emerging from the depths of my lungs) and I had to cancel the trip.

After processing multiple factors of risk versus benefit (not to mention the contribution to resistant bacteria), I decided to start myself on a Z-pak which is commonly utilized for community acquired pneumonia (does this mean I have a fool for a doctor?)

Azithromycin (the macrolide antibiotic in the Z-pak) , due to its broad antibiotic spectrum and perceived favorable safety profile, became one of the top 15 most prescribed drugs and the best-selling antibiotic in the United States, accounting for 55.4 million prescriptions in 2012.

The time between onset of electrical activation of the ventricles (Q) and the depolarization or reset of the ventricles (T) is called the QT interval. You can be born with a prolonged QT interval or it can become prolonged due to certain conditions. Prolonged QT intervals increase risk of sudden death
The time between onset of electrical activation of the ventricles (Q) and the depolarization or reset of the ventricles (T) is called the QT interval. You can be born with a prolonged QT interval or it can become prolonged due to certain conditions. Prolonged QT intervals increase risk of sudden death from abnormal rhythms like torsades de pointes type of ventricular tachycardia

Between 2004 to 2011, the FDA received 203 reports of azithromycin-associated QT prolongation (see graphic to the left) Torsades de Pointes (graphic) ventricular arrhythmia, or, in 65 cases, sudden cardiac death.

This prompted a review of Tennessee medicaid data which was published in 2012.

tdp
Torsades Des Pointes (fancy French word  for twisting of the points: note how the deflections seem to be oscillating slowly (somewhat like a sine wave I would have heard at Moogfest) . This is felt to be the way QT prolongation from medications like the Z-pak cause sudden death.

This study found that people taking azithromycin over the typical 5 days of therapy, had a rate of cardiovascular death 2.88 times higher than in people taking no antibiotic, and 2.49 times higher than in people taking amoxicillin. Most of the risk appeared to be those patients who had a baseline high risk of cardiovascular disease and the excess risk of death resolved after the 5 days of therapy.

As a result, the FDA added a warning to the azithromycin package insert and urged health care professionals to use caution  when prescribing it to patients known to have risk factors for drug-related arrhythmias, including those with long QT intervals, either congenitally or induced by drugs, low potassium or magnesium levels, slow heart rates or on other medications drugs used to control abnormal heart rhythms (amiodarone, sotalol and dofetilde). 

I survived my 5 day brush with a three-fold increased risk of sudden death and I really think the Z-pak substantially helped me get over the bacterial lung infection I felt I had. I knew my risk factors in detail and they were low. I was totally aware of any interacting drugs that could prolong my QT interval.

You can survive too. Make sure you definitely need the drug (i.e. you have a bacterial infection not just the common cold) and be cautious if you have any of the following

  • Family history of sudden death
  • Personal history of unexplained passing out or dizziness
  • Use of other medications that prolong QT interval (PDF)
  • Low potassium or magnesium levels (not uncommon in heart failure patients who are on water pills)
  • Severe heart disease of any kind

A complete listing is available here.

Meanwhile, Enjoy a sample of whatl I missed at Moogfest: Dorit Chrysler playing the theremin

 

 

 

How Starbucks is Making Heart-Healthy Coffee into A Stealth Dessert

Chemex
The Skeptical Cardiologist’s preferred method of making coffee-hand poured over freshly ground beans, filtered through a Chemex filter (yes, I know it’s laborious and the pictures aren’t as pretty as Starbucks, but it is really good!)

Many of my patients believe that coffee is bad for them. I’m not sure where this belief comes from; perhaps the general belief that anything that they really like and are potentially addicted to cannot be healthy.

It’s not uncommon for a patient to tell me after a heart attack that they have “really cleaned up their act” and have stopped drinking alcohol and cut back on coffee. They seem disappointed when I tell them that moderate alcohol consumption and coffee consumption are heart healthy behaviors.

In contrast to what the public believes, the scientific evidence very consistently suggests that drinking coffee is associated with living longer and having less heart attacks and strokes. Multiple publications in major cardiology journals in the last few  years have confirmed this.

You can read the details here and here. The bottom line is that higher levels of coffee consumption (>1 cup per day in the US and >2 cups per day in Europe) are NOT associated with:

  • Hypertension (if you are a habitual consumer)
  • Higher total or bad cholesterol  (unless you consume unfiltered coffee like Turkish, Greek or French Press types, which allow a fair amount of the cholesterol-raising diterpenes into the brew)
  • Increase in dangerous (atrial fibrillation/ventricular tachycardia) or benign (premature ventricular or supra-ventricular contractions) irregularities in heart rhythm

Higher levels of coffee consumption compared to no or lower levels IS associated with:

  • lower risk of Type 2 Diabetes
  • lower risk of dying, more specifically lower mortality from cardiovascular disease
  • Lower risk of stroke

So, if you like coffee and it makes you feel good, drink it without guilt, there is nothing to suggest it is hurting your cardiovascular health. It’s a real food. These tend to be good for you.

Making Coffee Unhealthy: Dessert as Stealth Food

People have always added things to coffee – cream, half and half, milk, skim milk, sugar, artificial sweeteners. The coffee data doesn’t reveal to us what the consequences of these additions are, but given the consistent positive health associations of coffee, they must have had a minor effect.

However, in the last 20 years, the food industry, led by the behemoth Starbucks (which controls 1/3 of the coffee served in the US and has 11,000 stores and growing) has turned coffee into a stealth dessert. Starbucks offers the consumer (by their own admission) 87,000 different choices of coffee drinks.
A basic coffee house drink is a latte’. This consists of one or more shots of espresso combined with steamed milk (skim, 2% or whole) and topped with foam. According to Starbucks, the 16 ounce, medium (I refuse to use their size terminology), cafe latte’ made with 2% milk, contains 17 grams of sugar and 7 grams of fat, yielding a reasonable 190 calories. Those who drink these should understand that they are consuming a glass of milk, plus coffee. Dairy products have consistently been associated with lower cardiovascular risk. They would arguably be better off consuming a whole milk (11 grams fat, 16 grams sugar, 220 calories) latte’ as I’ve pointed out in previous blogs here and here.

 

 

( Cinnamon Dolce Latte . Picture taken from Starbucks web site.

Most of the latte’s consumed at Starbucks aren’t plain latte’s, however; they are nightmares of added sugar. Let’s take the Cinnamon Dolce Latte’: (A complete nutritional breakdown is available from Starbucks’ website (I do congratulate Starbucks for finally capitulating and presenting nutritional data on their products at stores, allowing the public to draw back the curtain on the Starbucks Oz. Their website provides a cool way to compare your drink with whole/2%/skim/soy milk or with and without whipped cream)) It contains 38 grams of sugar, 6 grams of fat, and 11 grams of protein, yielding 260 calories, 152 of which are coming from sugar. That’s 22 grams more sugar, compared to their unadulterated latte’. (There must be an internet site devoted to promoting the health benefits of cinnamon since I hear about them so often from my patients but this claim is not evidence-based)

 

 

mochae frap
Picture of the Mocha Frappacino “Dessert” from the Starbuck website

My 17 year old daughter’s drink of choice at Starbucks is the Mocha Frappuccino® Blended Beverage, which, according to Starbucks, is “Coffee with rich mocha-flavored sauce, blended with milk and ice. Topped with sweetened whipped cream.” It contains 60 grams of sugar, 15 grams of fat and has 400 calories.

Such concoctions have no right to consider themselves coffee, they should be labeled as a sugar-laden dessert that happens to have some coffee in it. To give some perspective, the typical 20 ounce soda contains 40 grams of sugar (the equivalent of 10 packs of sugar).  Starbucks has added 44 grams of sugar to coffee and milk in order to draw children, teens and unsuspecting adults to consume more “coffee.”

There is growing evidence that sugar, not fat, is the major toxin in our diet. The misguided concept that cutting fat in the diet and replacing it with anything, including sugar, will reduce cardiovascular disease is gradually being rolled back. Nutritional advocates are now zeroing in on appropriate targets like sugary beverages.

It’s sad that Starbucks, which started out making a good, real product that was actually good for you, has morphed into an international, growth-obsessed, behemoth that is pumping billions of grams of added sugar into our stomachs.

But, as the significant other of the skeptical cardiologist (SOSC) often muses, people are always looking for new ways to con themselves into thinking they are eating/drinking something healthy, when in fact, they are just eating/drinking cleverly disguised desserts. Starbucks has made a huge success for themselves by providing people what they want: a way to kid themselves.

 

Searching for Subclinical Atherosclerosis: Vascular Screening

I reviewed in a previous post  the importance of detecting sublinical atherosclerosis when trying to assess someone’s risk of heart attack and of dying suddenly.  Subclinical atherosclerosis refers to the build-up of plaque in the lining of our arteries which occurs long before any symptoms of atherosclerosis occur.

Since the process tends to be diffuse, occurring in all the large arteries of the body, it makes sense that if we can easily visualize one artery this will give us a window into what is happening in other arteries (including the coronary arteries supplying blood to the heart muscle).

Vascular Screening

The vascular screening I offer in my office uses high frequency ultrasound to image the large artery, the carotid artery, that supplies blood to the brain.

normalimtNormally the lining of that artery is smooth and thin as in the example to the left. As the process of atherosclerosis works its damage on the artery lining it becomes thicker and plaque begins to develop. High frequency ultrasound is an excellent tool for identifying these early, subclinical stages of atherosclerosis because it is painless, harmless, inexpensive, and quick. 

Identifying Higher Risk Patients

Mr. M is  a 60 year old man who I was seeing for an abnormal heart rhythm. Using the ACC risk estimator I calculated his 10 year risk of atherosclerotic cardiovascular disease (ASCVD) as <7.5%. However, he had a brother who had cardiac stents placed in his coronary arteries (indicating coronary artery disease (CAD)). His carotid artery screening (shown below) shows a large, soft plaque

Large, relatively echo lucent (soft) plaque found in the internal carotid artery of Mr. M.

This indicates that although his known risk factors for atherosclerosis were not tremendously high, the combination of known and unknown factors (likely genetic, given his brother’s premature CAD) were damaging the lining of his arteries leaving him at a  high risk for stroke and heart attack.

 

A patient like Mr. M I consider to have documented atherosclerotic cardiovascular disease (ASCVD)and I  will strongly recommend statin therapy along with a baby aspirin

Several studies have shown in those patients who are reluctant to start statin therapy, documenting subclinical atherosclerosis serves as a strong motivational factor for lifestyle change or compliance with medications.

Identifying Lower Risk Patients

Equally important as identifying advanced subclinical atherosclerosis, imaging the carotid artery can identify those patients who are at lower risk and save them from a lifetime of unnecessary treatment.

Ms N is 64 years old whom I see h for high blood pressure and supra ventricular tachycardia (an abnormal heart rhythm). She has a total cholesterol of 219, HDL(or good) cholesterol of 74, systolic blood pressure of 130 and the ACC risk estimator gives her an 8.4% risk of ASCVD over the next 10 years. She greatly dislikes taking medications, but her mother died in her early fifties from  a “massive heart attack” .

huelsingHer carotid exam shows the carotid thickness as less than average for her age and gender, equivalent to that of a 58 year old. There is no plaque anywhere in her carotid system. I feel comfortable not recommending statins to this type of patient. In many cases, I often  stop cholesterol treatment in patients with no evidence for subclinical atherosclerosis who have marginal cholesterol levels and intermediate risk.

What vascular screening allows me is the ability to see if my patients do or do not have the disease that we are trying to prevent or mitigate: atherosclerosis.

As the skeptical cardiologist I must point out that national guidelines do not endorse vascular screening primarily because there are no randomized controlled trials showing that it influences outcomes. I’ll talk more about potential pitfalls of vascular screening when done by for profit ventures in a subsequent post  and we’ll discuss the other good way of assessing for subclinical atherosclerosis: coronary calcium.

 

Is A Snickers Bar Healthier Than Yoplait Yogurt?

This container of Yoplait comes from the refrigerator in the Doctor’s Lounge at my hospital. It is often the go-to snack for busy doctors and health conscious consumers.
I used to consider Yoplait about as healthy a snack as I could get. After all, it was low in fat, owned by French farmers and it had pictures of fruit on it. How could I go wrong?yoplait

In addition, Yoplait is focused on making “so good yogurt” as the company (now owned by General Mills) explains

“Ultimately, we’re focused on making so good yogurt, and here’s how we see it: you can eat something that tastes amazing but isn’t that good for you. You can eat stuff that’s really good for you, but doesn’t always leave you yummed up. So good yogurt does both. All of you is happy, not just your tongue. And while so goodness will never be perfect, we’ll keep working on ways to make our yogurt more so good than it is today.”

The significant other of the skeptical cardiologist (SOSC) made the claim recently that women who felt they were having a healthy lunch by consuming fat free yogurt and salad with sugary, fat-free salad dressing might as well be eating a candy bar. At least they would enjoy it more! Could this be true?

Yoplait made the bold step in 2012 of taking out the high fructose corn syrup they had been adding to their yogurt (or yoghurt as they like to spell it), but it’s still chock full of added sugar (which is probably why it leaves you “yummed up”)

What is now in “original” Yoplait?

Original Yoplait has 12 ingredients. They are Cultured pasteurized Grade A Low Fat Milk, Sugar, Blueberries, Modified Corn Starch, nonfat milk, kosher gelatin, citric acid, tricalcium phosphate, pectin, natural flavor colored with beet juice concentrate, Vitamin A and Vitamin D3.Yoplait_Original_Mountain-Blueberry

Indeed, the fat has been taken out but in its place – added sugar, 26 grams of sugar to be precise.

Of the 170 calories you are consuming, 104 of them are coming from sugar.

How healthy is a Snickers Bar?

snickers.jpgA regular-sized Snickers candy bar has a total of 280 calories with 13.6 grams of fat (5 grams saturated fat), 35 grams of carbohydrates (29 grams of sugar) and 4.3 grams of protein. It is made with peanuts, milk chocolate, egg whites and hydrogenated soybean oil. If we ate 2/3 of the bar to make the calories the same as the Yoplait, there would be 19 grams of sugar (compared to 26 for Yoplait) and 8 grams of fat.

A recent review of the cardiovascular effects of tree nuts and peanuts concluded:

there is impressive evidence from epidemiological and clinical trials and in vitro studies of beneficial effects of nut consumption and their constituents on the risk of CVD (cardiovascular disease), including sudden death, as well as on major and emerging CVD risk factors.

This is because in addition to a favorable fatty acid profile, nuts and peanuts contain other bioactive compounds that provide cardiovascular benefits. Other macronutrients include plant protein and fiber; micronutrients including potassium, calcium, magnesium, and tocopherols; and phytochemicals such as phytosterols, phenolic compounds, resveratrol, and arginine.


 

Curb your hunger.jpgSo, consuming 2/3 of a Snickers bar is arguably healthier than Yoplait. It contains peanuts, which have demonstrable benefits in lowering cardiovascular disease despite a high fat content. Yoplait has had the heart healthy dairy fat removed and replaced with added sugars. As I mentioned in a previous post, added sugar is clearly related to increased cardiovascular risk. The higher fat and fibre content of the peanuts in the Snickers bar will increase satiety and arguably be less likely to cause obesity due to rebound overeating later in the day.

A much healthier choice than low fat, added sugar products like Yoplait (and candy bars) is full fat, plain yogurt (preferably from grass-fed cows) as I’ve discussed in previous posts. It can be combined with real fruit or even with nuts. Full fat yogurt is surprisingly hard to find on a grocery shelf. Even at Whole Foods, the vast majority of yogurt and dairy products are low fat. I’ve only been able to find two brands, Supernatural and Trader’s Point Creamery, which consistently offer full fat yogurt.

Disclaimer and clarifications

godzilla.jpgI do not receive any payments from Snickers nor from Mars, Inc., one of the most known and beloved brands of chocolate.  I do not plan on seeing Godzilla, May 16. Although Snickers loves you, you do not need to like Snickers.snickersloves you.jpg

 

 

 

 

 

Searching for Subclinical Atherosclerosis: Am I about to drop dead?

Nearly every day I see a patient in the office who has just experienced a friend or relative suddenly “dropping dead.”  Understandably, they are very concerned about this and want to know “Is this going to happen to me?”

There is very good reason to be concerned. Cardiac disease is the leading cause of death in America. Despite considerable progress, regrettably 50% of deaths occur suddenly, without any previous symptoms which would have suggested a cardiac problem. It doesn’t just hit the overweight or the smoker. It not uncommonly strikes the very fit and seemingly healthy, as in the case of the St. Louis Cardinal pitcher, Daryl Kile, who was found dead in his hotel room at the age of 34. This question of who is going to suddenly drop dead (sudden cardiac death or SCD) is one of the fundamental unsolved mysteries in current cardiology.

Atherosclerosis and Dropping Dead

Most SCD in individuals over the age of 35 is related  to the development of fatty plaques (atherosclerosis) in the arteries that supply blood to the heart (coronary arteries) and the subsequent sudden rupture of these plaques (thrombosis).hrtatk-07 The result of this rupture is the complete blockage of the artery and the total cessation of blood flow to a portion of the heart muscle. When that heart muscle portion becomes starved for oxygen, the muscle cells start dying and a myocardial infarction (MI) or heart attack occurs. You can view an animation of this process here With any MI, the dying muscle cells can become electrically irritable and initiate an abnormal heart rhythm called ventricular tachycardia (VT) or ventricular fibrillation (VF). This abnormal rhythm is what causes people to “drop dead” suddenly. Basically, the heart cannot pump blood efficiently in VT or VF; thus, there is no blood flowing to the brain and other vital organs. This is a long, complicated chain of events, but basically it begins with the development of fatty plaques or atherosclerosis. It makes sense that we can stop people dropping dead from MI by stopping the development and progression of atherosclerosis. Atherosclerosis develops long before any clinical signs or symptoms of disease. You can feel totally fine and have a huge build up of plaque in all of the arteries of your body. This is termed subclinical atherosclerosis. It makes sense, and it has been scientifically proven, that those with a huge buildup of plaque (high plaque burden) are at higher risk for MI and death than those with low or no plaque burden. It also makes sense that treating those patients with high plaque burden will be most beneficial.

How Do you know if you have atherosclerosis

I discussed the standard recommended method for determining risk of MI/SCD in my last post on statins. Basically, this is simply adding up the factors we know contribute to atherosclerosis: diabetes, cigarette smoking, hypertension, age, gender and cholesterol levels. However, most heart attacks and strokes occur in people who are classified by traditional risk factor scoring as low or intermediate risk. Conversely, others are misclassified as high risk and mistakenly advised to take drugs to reduce their risk factors for the rest of their lives.

How Can We Detect Subclinical Atherosclerosis?

In my office practice I offer patients two tests which directly detect and quantify subclinical atherosclerosis. One looks for plaque  and thickening in the larger arteries of the neck, the carotid arteries, and one looks for calcium in the coronary arteries. I’ll go into detail about both of these in subsequent posts. For now, I will just say that the carotid screening technique uses harmless ultrasound while the coronary calcium technique uses ionizing radiation from a CT scan. Neither test is covered by insurance or Medicare. Both tests have been shown to improve our ability to identify those at risk for MI and stroke.

These tests are helpful in two general areas:

*The first scenario is the patient who appears to be at low or intermediate risk for atherosclerosis based on the risk estimator, but who has a strong family history of MI, sudden death or stroke. If we identify significant subclinical atherosclerosis in this patient, statin therapy is more likely to be beneficial.

*The second scenario is the patient who has been put on statins for primary prevention based on standard risk estimator but has no family history of ASCVD and is questioning the need for treatment. In this patient if we find no subclinical atherosclerosis, a strong argument can be made to stop the statin drug.

SHAPE Guidelines II Slide_Page_38
Proposed method for utilizing carotid vascular and coronary calcium tests for better identification of subclinical atherosclerosis and more appropriate utilization of treatment in order to prevent heart attacks and sudden cardiac death

There is an organization dedicated to promoting the detection of SA by these tests and an algorithm for treatment called SHAPE  (Society for Heart Attack Prevention and Education). Interestingly, after a female Texas state representative suffered an MI, in 2009, Texas Governor Ricky Perry signed off on the Texas Heart Attack Prevention Bill mandating health-benefit plans to cover screening tests for SA. No other state to my knowledge has such a law.

How to Stop Sudden Cardiac Death

The two tests I mentioned are a good second step towards identifying the individual at risk for MI and SCD but we still don’t know who among those with advanced subclinical atherosclerosis is going to experience a sudden rupture of plaque, have an MI and drop dead.

We need a way to identify those patients with vulnerable plaque (one that is about to rupture) and aggressively treat those patients. This is an area of intense research focus. You can view a fascinating video (accompanied by weirdly cool music) created by SHAPE here and another (featuring a gun shooting a heart) here emphasizing the importance of the vulnerable plaque.

Should I Take A Statin Drug? Risks, Benefits and the New Guidelines

StatinsThe skeptical cardiologist just returned from Washington, DC where he attended the American College of Cardiology (ACC) annual conference and visited Ford’s Theatre. I was hoping to gather more information on diet and cardiovascular disease but most of the discussions on prevention of heart disease centered around the new ACC/AHA guidelines for treating cholesterol.

A recently published analysis of the impact of these guidelines found that

As compared with the ATP-III guidelines, the new guidelines would increase the number of U.S. adults receiving or eligible for statin therapy from 43.2 million (37.5%) to 56.0 million (48.6%). Most of this increase in numbers (10.4 million of 12.8 million) would occur among adults without cardiovascular disease.

If you are a man over the age of 59 (which I just became), even without any cardiovascular disease or diabetes, there is an 87% chance the guidelines would suggest you take a statin drug.

This is a startling increase and consequently there has been a lot of criticism and questioning of the validity of these recommendations.

More importantly, for an individual patient, should you take a statin drug if your doctor recommends it? This is an especially good question if you have no evidence of any atherosclerotic cardiovascular disease (so-called primary prevention). At a minimum, you should have a very detailed discussion with your doctor about the risk and benefits of taking the medication in your particular situation.

What are statin drugs?

Statins are the most powerful, safe and effective drugs available for lowering LDL or bad cholesterol levels. They inhibit 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase, involved in cholesterol biosynthesis. Low density lipoprotein (LDL) cholesterol concentration is lowered by reducing its production in the liver and increasing removal from the circulation. Statins also have anti-inflammatory effects, improve endothelial function, and reduce thrombus formation.

Common examples of statin drugs are Lipitor which is now available as a generic called Atorvastatin , Pravastatin, and Crestor (Rosuvastatin), which is only available in brand name form.

What are the risks of statin drugs?

When large scale randomized trials of statin drug therapy are analyzed, rates of adverse events (17%) or stopping treatment due to adverse events (12%) are similar in the statin compared to placebo/control groups.

The incidence of cancers, liver enzyme elevations, kidney dysfunction or arthritis was the same in the two groups.

There are only two side effects from taking statins I consider significant and mention to my patients:
1. There does appear to be a 9% increase in the risk of developing diabetes. Most of the patients who develop diabetes on statins were at high risk for this to begin with and the overall benefits of lowering CV disease outweighs the development of diabetes in patients who take statins.
2. Statins definitely can cause muscle aches (myalgias) and this seems to happen in about 10% of patients over time. If these develop, we stop the statin and the myalgias go away if they are due to the drug. There are no reliable studies showing any long term residual muscle weakness or ache. A very, very small number of patients develop rhabdomyolysis, in which there is severe muscle damage. These patients are almost always taking multiple medications which interact with the statins and often have kidney failure to begin with.

Some things you don’t need to be concerned with while on statins:

1. That the drug will give you Alzheimer’s or make you stupid. There is much anecdotal misinformation on the web about this, but no solid evidence of any adverse effect on cognition.
2. That the drug will destroy your liver. A small percentage of patients will develop elevations of their liver enzymes (AST or ALT) but this does not lead to liver damage and is considered so insignificant now that the FDA now longer advises checking liver enzymes in patients on statin drugs.

What are the benefits of statins in people without known heart disease?

They lower all-cause mortality by 14%, combined fatal and nonfatal cardiovascular disease by 25%, and stroke by 22%. They lower the chances that you would need a stent or bypass surgery by 38%.
Another way of looking at the benefits of a treatment is the number needed to treat (NNT).
To save one life, you would need to treat 138 patients for 5 years with statin drugs. This means that 137 patients would have done fine without taking the drug.

The higher your risk of developing atherosclerotic cardiovascular disease  (ASCVD (all the disease that occurs as a result of fatty plaque build up in the body, including heart attack and stroke)), the more likely you will benefit from taking a statin drug.
Thus, the new guidelines utilize a risk estimator that takes into account your total and good cholesterol values, your systolic blood pressure, age and whether you smoke, have diabetes or treated hypertension to calculate your risk of developing clinical ASCVD over the next ten years.

If this ten year risk is over 7.5%, statin therapy should be considered.

I’ve looked over the guidelines carefully, read a lot of the original studies and listened to the discussion and I think this is a reasonable approach. I try to present each patient with the risks and benefits and let them make the decision as to whether they want to take the drug.
Each individual has a different perspective, perhaps heavily influenced by their father having died of a heart attack in his fifties or by a close friend who feels that statins ruined his life.

Two important new concepts from the new guidelines

The new guidelines no longer look at the LDL or bad cholesterol level as a goal or as a level for initiating treatment (unless it is super high, above 190). Thus, the only reason to be checking follow up cholesterol panels on patients who are taking good levels of statin drugs is to verify compliance and an effective reduction in LDL from baseline. I will not try to get your LDL below 100 or 70 and you will not have to worry that it is not at that level.

The new guidelines rightly emphasize statin drugs as the only drug therapy that has good outcomes data (meaning they have been show to reduce heart attacks and strokes) supporting their use in primary prevention.
Ezitimibe (Zetia) is a commonly prescribed drug which lowers LDL cholesterol but is expensive and has never been shown to lower heart attack or stroke risk and, in my opinion, should not be prescribed.

Our goal should be prevention of heart disease, not lowering LDL levels or triglyceride levels.

I believe that we can fine tune which patients will and will not benefit from statin therapy by looking for evidence of what is called “subclinical atherosclerosis.” I plan to review this in a future post.
For now, I leave you with the humorous line from the play “Our American Cousin” that caused the distracting laughter during which John Wilkes Booth shot Lincoln in Ford’s Theatre (which is not far from the Washington Convention Center and well worth visiting!)

“Don’t know the manners of good society, eh? Well, I guess I know enough to turn you inside out, old gal — you sockdologizing old man-trap.”

Tell your cardiologist you will sockdologize him if he doesn’t give you a good discussion of the risks and benefits of the statin drug he is recommending.

Why I Recommend the Mediterranean Diet

I recommend the Mediterranean diet (MED) to my patients. Every unbiased, systematic review of the research on diet and heart disease in the last 8 years has concluded that it is the most likely dietary model to provide protection against coronary heart disease. One review concludes

Among the dietary exposures with strong evidence of causation from cohort studies, only a Mediterranean dietary pattern is related to CHD (coronary heart disease) in randomized trials.

The MED is the only comprehensive dietary approach that has been proven to reduce total death  and heart attacks in comparison to standard diets. There are two major randomized controlled trials (the only kind of study that proves the value of a dietary intervention) with this diet.

lyon
From Eric Roehm at www.nutritionheart.com

  The first, called the Lyon heart Study,  was in patients who had had heart attacks (secondary prevention) . As this graph demonstrates, those patients randomized to receive instruction on following the Mediterranean diet had a 60% lower death rate and a 70% lower heart attack rate. The second was published last year in the New England Journal of Medicine and was a primary prevention study: that is, participants had not had heart attacks. Participants were randomized to one of three diets: a MED supplemented with extra-virgin olive oil,  MED supplemented with mixed nuts or a control diet (advice to reduce dietary fat). Participants received quarterly individual and group educational sessions and either free provision of olive oil, mixed nuts or small nonfood gifts. The high extra virgin olive oil group ingested an average of 3.6 tablespoons/day (51 grams/day equal to 459 calories/day) of olive oil with 98% of it being extra virgin olive oil. The high nut group ate 8.2% of their total daily calories in the form of nuts, including an additional approximately one ounce packet of nuts (15g of walnuts, 7.5 g of almonds, and 7.5g of hazelnuts) provided by the study coordinators. 7447 persons were enrolled (ages 55 to 80 years) for an average 4.8 years. Those persons following the MED diet (either supplemented with olive oil or nuts) were 30% less likely to have  a major cardiovascular event (heart attack, stroke or death from cardiovascular causes.) There was a statistically significant reduction in stroke rate (≈39%) when considered as an isolated endpoint. We don’t know exactly what components of the MED are the most beneficial.  This trial suggests that olive oil and nuts are at least two of the key ingredient so it makes sense to increase your consumption of these foods. Other studies strongly support fish consumption and alcohol consumption as key components. As I’ve discussed (?ad nauseam) in other posts, full fat dairy and eggs, although banned by most “heart healthy diets”, have not been shown to increase heart disease risk.  Fermented dairy consumption, in particular, in the form of plain full-fat yogurt (not adulterated with sugar) and full-fat cheese is consistently associated with a lower risk of coronary heart disease. Plain full-fat yogurt and full-fat cheese (from goat milk) were consumed by the inhabitants of Crete, the Greek Island on which the original MED was based.

It has to be emphasized that within this pattern of eating you want to be consuming real foods, not processed products of the industrial food industry which have been manipulated to appear healthy due to being “low-fat” or “low cholesterol.”

This is a pattern of eating which is varied, interesting and sustainable.

It’s one that can last a lifetime. ,

Full Fat Dairy Lowers Your Risk of Obesity

ButterWhen i tell my patients that I am fine with them consuming full fat dairy products including butter I see  a mixture of responses. For many, there is a great relief that the butter they have been avoiding for the last 20 years (or consuming guiltily) can now be used. For others, the prospect of consuming full fat milk, cheese or yogurt still seems risky. After all, they have been hearing from the American Heart Association, the USDA nutritional guidelines and pretty much every nutritional advice column for the last 30 years that these products increase their risk of heart disease and contribute to obesity. Why should they believe their local cardiologist, a lone voice promoting full fat dairy against a chorus of naysayers?
Hopefully, by continuing to present scientific research on the topic I can make this concept more acceptable and counter the misinformation that is so prevalent

Researchers in Sweden have followed a cohort of rural men for over 12 years. In a previous study they found that daily intake of fruit and vegetables in combination with a high dairy fat intake was associated with a lower risk of coronary heart disease. Recently they examined their data to answer the question : how does dairy fat intake impact on the risk of developing central obesity in this middle-aged male cohort?

What is central obesity?

Central obesity refers to fat that builds up inside the abdomen. It is often measured by measuring the waist circumference: > 102 cm for males and 88 cm for females is a  marker of central obesity. Central or abdominal obesity indicates insulin resistance and is part of the metabolic syndrome and well known to increase the risk of diabetes.  It is also associated with heart disease, various cancers, and dementia. In this Swedish study, central obesity was defined as waist hip ratio ≥ 1.
The study found that 197 men (15%) developed central obesity during follow-up. A low intake of dairy fat at baseline (no butter and low fat milk and seldom/never whipping cream) was associated with a higher risk of developing central obesity (OR 1.53, 95% CI 1.05-2.24) and a high intake of dairy fat (butter as spread and high fat milk and whipping cream) was associated with a lower risk of central obesity (OR 0.52, 95% CI 0.33-0.83) as compared with medium intake (all other combinations of spread, milk, and cream) after adjustment for intake of fruit and vegetables, smoking, alcohol consumption, physical activity, age, education, and profession

Yes, these data show that participants were three times more likely to develop central obesity if they consumed skim milk and no butter compared to those who drank high fat milk and butter.

This is not an isolated finding. There is a wealth of data supporting the concept that full fat diary is less associated with obesity and markers of the metabolic syndrome, diabetes and insulin resistance.

120px-CheeseAnother recent study in a Basque population in Spain found that  participants with low or moderate consumption of cheese (high fat) compared to high consumption of cheese (high fat) had a higher prevalence of excess weight

Why do people falsely believe that fat in general and high fat dairy in particular promotes obesity?

In the past, supporters of this concept (and there are less and less in the scientific world)  would point to the energy density of fat which contains 9 calories per gram compared to 4 calories per gram for carbohydrates or protein. Obviously, if obesity is determined by calories in versus calories out then the food with more % fat compared to carbs or protein is providing more calories. All things being equal, one could expect to grow fatter on the higher % fat diet. All things are not equal, however, because one doesn’t determine how much one consumes based on the volume or weight of the food entering the mouth.

There are far more complex factors at work. How does the mixture of food components effect satiety? What is the insulin response to the food? What are the other components of the food such as vitamins, fiber, calcium and how do they interact with food absorption and metabolism?

So, even though this contradicts what has been drummed into your head for 30 years: eat full fat yogurt , cheese and milk , not fat-free, if you want to avoid getting fat

Unbiased, evidence-based discussion of the effects of diet, drugs, and procedures on heart disease

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