All Posts tagged stroke

Cholesterol Meds – Awesome or Awful?

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.


Bell’s Palsy

​What are you supposed to think when you wake up and half of your face isn’t working? That was the question one of my patients recently had to ask herself. When she smiled in the mirror, only the left side of her mouth went up. When she tried to close her eyes, only the left eye closed. And when she tried to lift her eyebrows, only the left eyebrow worked, and only the left forehead wrinkled. She brushed her teeth and tried to swish out her mouth and the water went spilling out of the weak side of her mouth. Stroke? Fortunately not, although when in doubt it’s always best to get immediately to the ER.

​One clue that this was Bell’s palsy and not stroke was the lack of movement of the right forehead. When a stroke is the cause, the forehead is usually spared and still moves (wrinkles) on both sides – we won’t get into the whole reason for that – but with Bell’s palsy it doesn’t.

​So what is this stroke-mimicker that affects only the face? Bell’s palsy is an acute affliction of the facial nerve. It results in rapid paralysis or weakness of the facial muscles on one side of the face, usually progressing over up to 48 hours. The cause still isn’t definitively known. It can happen at any age, but its peak prevalence is in 40-49 year olds.

​Along with the one-sided facial paralysis, there may be altered taste and loss of tear production on the affected side. There also may be pain around the ear and sometimes vision is blurred on the affected side.

​Treatment involves first making sure it’s Bell’s palsy and not a stroke. If the symptoms aren’t clear-cut, a cat scan or MRI of the head is sometimes done to rule out tumor or stroke. Steroids are the preferred treatment and antiviral agents may sometimes improve outcomes slightly as well. ​

​The good news is that in 80-90% of cases, the symptoms slowly clear over a few months’ time. In the meantime, the affected eye needs to be protected with frequent lubrication, and sometimes taped shut overnight to avoid drying out and damaging the cornea. Facial physical therapy is sometimes used but hasn’t really proved to make a notable difference in the rate of recovery. Various surgical procedures are used only rarely to aid eye closure in those cases where the paralysis proves permanent.

​So, while Bell’s palsy certainly beats a stroke, it’s no picnic and can be very slow to resolve, or rarely, may not resolve fully. And as we said at the beginning, always best to get to the ER immediately with any sudden paralysis or loss of function.

Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville. Contact him at 982-0835