Statins – those frequently-prescribed cholesterol-lowering medicines that include Zocor (simvastatin), Lipitor (atorvastatin), Crestor (rosuvastatin), Livalo (pitavastatin), Mevacor (lovastatin), Lescol (fluvastatin), and Pravachol (pravastatin) – are they awful toxins or awesome remedies? You can certainly read both opinions if you follow the news or scan the web. The New York Times once touted them as “the underused wonder drugs” while other articles and blogs claim they are dangerous and no one should use them. Meanwhile they are the most prescribed drugs in the world and over 20 million Americans take them.
So where is the truth when it comes to statins? No one can credibly claim that they don’t effectively lower cholesterol. We routinely see up to and beyond 100 point drops three weeks into treatment with a statin. What’s more, they act as anti-inflammatants inside the blood vessels and inflammation promotes plaque formation (the stuff that damages and blocks arteries leading to heart attacks and strokes). But does lowering cholesterol and inflammation translate into reduced heart attacks, strokes, and overall mortality? For high-risk individuals who have already had a coronary event (a heart attack or stent or bypass surgery) the answer is clearly, yes. Statins reduce the chance of a second heart attack by about a third.
However, in what’s called primary prevention – preventing bad outcomes in individuals who are at lower risk and have never had a coronary event – the numbers are still there, but not quite as compelling. An analysis of 14 randomized trials involving almost 35 thousand patients showed the following:
- 17% reduction in all-cause mortality
- 28% reduction in heart attacks
- 22% reduction in strokes
- No significant additional adverse events in those treated vs. placebo groups nor negative effect on quality of life
That sounds fairly impressive, but put another way, when the numbers are worked out, 1000 people would have to be treated for one year to prevent one death. So there is a real, but modest benefit in treating lower risk individuals with statins.
On the side-effect side of the equation, we already noted that substantial side effects seem to be statistically insignificant in the studies. But that’s not the whole story. Liver effects are actually rather uncommon, with a significant rise in liver enzymes occurring in roughly 1 in 100 patients. If they occur, the statin is simply stopped and the enzymes return to normal. Actual liver failure rates in those on statins are almost the same as those in the untreated population.
Muscle pains occur in some 10% (estimates vary) of those on statins and, again, generally resolve promptly when the statin is stopped. More serious muscle damage can occur, though rarely (in over 25 years of prescribing I’ve not had my first yet). Other recent findings note a slight rise in blood sugar with statins and a fairly uncommon incidence of mental fuzziness and memory issues. If the latter occurs, the statin can be stopped and the problem clears. All in all, my experience has been that some 8 out of 10 persons put on statins have no problem.
So, in the real world, if you have high cholesterol, how do you decide whether to be on a statin? Sit down with your physician and go over your cholesterol numbers in detail. Then look at all your other risk factors for heart disease and stroke (smoking, hypertension, diabetes, family history, sedentary life style, etc.). For many I also recommend a coronary calcium score (a rapid, non-invasive CT of the coronary arteries looking for calcified plaque), a cardiovascular inflammation panel (I use Cleveland Heart Lab), and sometimes a CIMT (carotid intima media thickness, an evaluation of the state of plaque formation and inflammation in the blood vessels). These tools give us a much better handle on who really is showing blood vessel damage and risk and who isn’t. This allows us to target our preventive efforts, including statin use, on those who will most benefit from it. Of course in all of this, don’t forget lifestyle changes such as the one highlighted in another New York Times article: “Underused Therapy for the Heart: the Gym.”
So statins are neither simply awesome nor awful; they’re one treatment that may or may not be right for you, when added to your steady efforts to minimize all those other risk factors.
“I was late rushing over here.” “Traffic was terrible.” “I just had a cup of coffee.” “Work’s been really stressful.” “My blood pressure’s only high when I’m here in the office. I can feel when it’s high and it’s never high at home.”
For some reason, when I mention that someone’s blood pressure (BP) is high (also called hypertension when it’s consistently high) more often than not some reason is given to explain it away. And there can be some truth to some of these reasons. For example, “white coat hypertension,” where someone’s BP seems to mostly be high from tensing up in the doctor’s office, is a real thing. However, even here, those who have it have been found to have increased risk compared to those who don’t.
The bottom line is that high BP is:
• extremely common, with about one in three adults, as well as many children (19% of boys and 13% of girls and rising) having it
• usually without symptoms (until it causes a catastrophe such as stroke, heart attack, heart failure, an aneurysm, kidney failure or loss of vision)
• crippling and/or deadly, as seen from the list of severe consequences noted above
So high BP is common and deadly but silent for years and so often ignored. In fact only about half of those with high BP have it under control. Although lots of folks think they can feel it when their BP is high, it turns out that when this is tested, almost no one can reliably tell whether there BP is high unless it is extreme (like 220/120). And we don’t want our first clue that we’ve had untreated high BP to be that we wake up with the squeezing chest pain of a heart attack, or that we suddenly can’t speak right, or our left side isn’t moving because we’re having a stroke. So the bottom line is you need to measure BP, preferably at various times of the day under varying levels of stress to get a sense of where your range is.
What’s recommended as a healthy BP? Well that number may have recently gotten a bit lower. In a recently published study, those treated to a BP under 120/80 did so much better compared to those only treated to the less aggressive goal of under 140/90 that the study was stopped early. It was considered unethical to not treat all of the patients to the lower goal. The top number (systolic) proved to be particularly important to control aggressively. Specifically, the group taken down to the lower (120/80 or below) goal had a 27% lower incidence of events such as heart attack and stroke. This study was comprised of folks who were over 50 years old and had at least one other risk factor for heart disease or stroke.
So, we can reasonably say that for the over 50 crowd with at least one other risk factor (such as smoking, diabetes, high cholesterol, family history of heart disease), shooting for the 120/80 goal is ideal if it can be done without a lot of side effects. Only about 5% of folks treated to the lower (120/80) goal had substantial side effects such as light-headedness with standing. And the percentages weren’t that different in the 140/90 treatment group.
Okay, then how do we treat high BP?
• If you smoke, you really need to quit
• Slowly shave off those extra pounds
• Regular aerobic exercise if your doctor clears you for it (such as a 3-4 MPH walk for 30 minutes at least every other day)
• Choose low salt foods (60% of people with high BP are made worse by high salt intake)
• No more than 1 (for women) or 2 (for men) alcoholic drinks per day
• Avoid decongestants and anti-inflammitants — they raise BP
• Manage stress (always easier said than done)
If in spite of your efforts the numbers just aren’t getting where they should be, it’s time to talk with your doctor about medicine options. It may not excite you to take a medicine, but it beats a stroke, heart attack or any of the other problems on the list. And there are enough medicine choices where you can almost always find one (or a combination) that doesn’t hassle you with side effects.
If I can be appropriately dramatic, untreated high BP is kind of like an axe murderer who we let hang around our home because he is quiet and polite and mostly stays out of our way… until one day he strikes, devastatingly. Likewise, when we treat high BP we won’t necessarily feel any better. But we will have tied up the murderer in a corner so that he can’t harm us.
So see if high BP is lurking quietly around your house. And if you find him, don’t explain him away; take him seriously, tie him up and then check on him often enough to be sure he stays put.
Maybe it’s the countless images of hearts everywhere I turn during this Valentine’s Day season, but it seems we should talk a little about protecting our hearts. If we were living in the U.S. in 1900, the top three causes of death would all be infectious diseases: flu and pneumonia (lumped together), tuberculosis, and gastrointestinal infections. And I probably wouldn’t be writing this article since the average life expectancy for men was 46 years old.
With the introduction of vaccinations, antibiotics, and overall better nutrition and sanitation, these infectious causes have retreated substantially. In their place, and reigning as the number one cause of death for many decades, is heart disease. It currently causes almost three out of every ten deaths.
One of the major forms of heart disease is coronary artery disease (CAD), in which the arteries supplying the muscle of the heart become blocked. When that happens, the oxygen- starved muscle generally hurts, causing a kind of chest pain we call angina. If the coronary artery is completely blocked, the part of the heart muscle it supplies dies. This is what’s going on in a heart attack (medically termed a myocardial [heart muscle] infarction [tissue death due to blocked blood supply]).
The stuff that blocks arteries is called plaque. Risk factors for plaque, and thus for heart attacks (as well as the strokes which happen by a similar process) are:
- High blood pressure
- High cholesterol
- Physical inactivity
- Having a family history of early heart disease
- Increasing age
As you can see, several of these risk factors are manageable. One of the problems with prevention is that CAD is often a silent process until critical blockage occurs. Of course knowing the risk factors and working to combat lifestyle issues such as lack of exercise, overweight, smoking, and even diabetes is huge when it comes to prevention. In addition rather simple tests such as coronary calcium scores (a fairly inexpensive low dose cat scan picture of the arteries around the heart) can give further information about plaque on the coronary arteries. It’s not a perfect test, but it correlates pretty well with risk for future heart attacks or angina.
So as Valentine’s Day 2014 recedes into the past, as you ponder the status of your emotional heart, give your physical heart a little thought as well. If you have some reversible risk factors, go after them this year. And if you really don’t know the status of your cholesterol, blood sugar, or blood pressure, get them checked out. Also, see if your doctor recommends a coronary calcium score or other testing to further assess the status of your heart. All-in-all, it’s better to be aggressive with prevention now than with stents and bypasses later.
Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville. Contact him at 982-0835