The Truth About Statins

Risks and Alternatives to Cholesterol-Lowering Dru

Barbara H. Roberts

• Publisher: Pocket Books
• Year: 2012
• ISBN:
  9781451656404
• Topic: Medicine
• Subtopic: Diseases & Allergies

COULD STATIN DRUGS ACTUALLY HARM YOU? Despite the rosy picture painted in the ads of a miracle cure for high cholesterol and its attendant heart disease, the reality of taking statins may be far less pretty. Dr. Barbara H. Roberts, director of the Women's Cardiac Center at the Miriam Hospital in Rhode Island, discusses both the benefits and health risks of these popular drugs in this comprehensive guide that finally reveals the questionable science behind the research studies. This honest, patient-friendly appraisal of the most widely used medications in the world may shock you, but it may also save your life. Offering clear-cut, easy-to-understand information in an easily accessible fashion, Dr. Roberts explains how to take the best possible care of your heart, including: * The keys to maintaining cardiovascular well-being * How to interpret your cholesterol numbers * The frightening adverse effects of popular drugs It is time to take charge of your heart health. Learn the facts behind the hype so that you can make informed decisions on a subject vital to your continued health. If you or someone you love either takes a statin or is considering doing so, you need to read this book. Includes recipes for a delicious and heart-healthy diet, including Wasabi-Roasted Salmon, Pasta with Avocado Sauce, and Lemon-Pineapple Breakfast Muffins.

Part 1

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ARE STATINS FOR ME?

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— Chapter 1 —

My Doctor Wants Me to Take a Statin—What Questions Do I Need to Ask?

Mrs. R.G. is a forty-five-year-old woman who is in good health. She has a yearly checkup with her primary care doctor, who has told her that she needs to lose weight. She works full time as an accountant and has two teenage children. She also cares for her parents, who are in their late seventies and chronically ill: her mother with severe arthritis and her father with blindness from macular degeneration. With little time for exercise, she has gained thirty pounds since graduating from college. She also “de-stresses” by eating cookies and candy. Her most recent cholesterol numbers reveal that her total cholesterol is 255, her triglycerides (another blood fat) are 200 (normal is up to 150), her HDL, or “good,” cholesterol is 50, and her LDL, or “bad,” cholesterol is 165.

Her doctor tells her to go on a low-fat diet and prescribes the statin drug simvastatin (brand name, Zocor) to get her LDL cholesterol down. Within two weeks of starting this medicine, she has severe muscle pain and difficulty concentrating. She goes online and looks up statin side effects. Convinced that she is suffering adverse effects from the simvastatin, she calls her doctor, who orders a blood test to look for muscle damage. The test comes back normal, so her doctor tells her that the statin is not causing her symptoms. Mrs. R.G. stops the statin anyway, and within a few weeks, her muscle pain and difficulty concentrating are gone.

A Brief Primer on Cholesterol

What is cholesterol, and why do we need to be concerned about it if the level is considered high? If your doctor tells you your cholesterol is 250, for example, what does that mean?

In addition to being manufactured in the body, cholesterol is also found in foods derived from animal sources. Cholesterol serves many important functions in our bodies. It’s an integral part of the cell membrane that surrounds every cell in our bodies, keeping all the structures inside the cell from leaking out. It is a building block of other molecules that our bodies need to function, such as vitamin D, and many hormones. Cholesterol is used to make bile acids, which assist in digestion.

Cholesterol circulates in the blood bound to special proteins called lipoproteins, which are classified according to their density. (Lipos is a Greek word meaning “fat.”) So LDL cholesterol is low-density lipoprotein cholesterol (“bad cholesterol”), and HDL cholesterol is high-density lipoprotein (“good cholesterol”). VLDL cholesterol, made up mostly of triglycerides, is very-low-density lipoprotein that, when elevated, increases the risk of ASCVD. Taken together, these lipoproteins are referred to as blood fats or blood lipids. Although cholesterol is absolutely essential for life, high levels of certain lipoproteins (and low levels of HDL cholesterol) can be harmful because they increase the risk of developing plaque in the arteries, the blood vessels through which oxygenated blood reaches all the body’s cells. Atherosclerosis, the name for this process, underlies most heart attacks and strokes.

Our lipoprotein levels are determined both by our genes and by our lifestyles. For example, people who consume diets that are high in starchy carbohydrates will often have high triglyceride levels. Those who eat large amounts of animal fat (found in meat and dairy products such as milk, butter, and yogurt) will often have high levels of LDL cholesterol. There are some people with a rare familial form of high cholesterol who have very high levels of LDL cholesterol even if they are strict vegetarians.

How Cholesterol Is Measured

Cholesterol and triglycerides are usually measured on a fasting sample of blood. You will be told to fast for twelve hours. (You may drink water but should not eat or drink anything that has calories.) A blood sample will be taken and then spun in a centrifuge to separate the red blood cells from the clear part of the blood (plasma). The plasma will then be analyzed by a machine that measures the total cholesterol, the triglyceride level, and the HDL cholesterol. The level of LDL cholesterol is then calculated using a formula. (It can be measured directly, but this is generally not done unless the triglyceride level is very elevated, because in that instance, the calculated LDL cholesterol level is inaccurate.)

The cholesterol values are reported as milligrams per deciliter, abbreviated mg/dl. A gram is a unit of weight, and a milligram is one-thousandth of a gram. A potato chip weighs about 1 gram (1,000 milligrams), so you can see that we’re talking small quantities here. A deciliter is one-tenth of a liter, or about 3 ounces of liquid. So a total cholesterol level of 250 mg/dl means that there is an amount of cholesterol weighing about the same as one-quarter of a potato chip in 3 ounces of plasma.

Evidence-Based Medicine

The patient described at the beginning of this chapter is a composite drawn from many people I have seen in my office over the years. Throughout this book you will read the stories of actual patients who have been harmed by statins, but I used Mrs. R.G. as an example of the patients I often see who are put on statins even though they do not meet the current guidelines for using these medicines. Nowadays, doctors are urged to practice what is called “evidence-based medicine.” In other words, we are urged to use only those medicines or procedures that have been proven by scientifically valid clinical research studies to have more benefits than risks.

In chapter 7, I will discuss the somewhat checkered history of clinical research, but to simplify a complex subject for the purposes of this chapter, when and how to treat cholesterol, based on the best available scientific evidence, is spelled out in the Adult Treatment Panel III guidelines from the National Cholesterol Education Program (NCEP), established by the National Heart, Lung, and Blood Institute. Unfortunately, the guidelines are published in lengthy articles that the average doctor is too busy to read in detail. Many doctors read that the “optimal” LDL cholesterol is under 100, and they come away feeling that anyone whose LDL cholesterol is over that number should be on medicine. The upshot is that many people are taking statin medicines unnecessarily, and a significant proportion of them are being harmed.

Among the well-known side effects of statins are muscle pain and inflammation, and damage to many other organs, including the liver, tendons, nerves, and the brain. And since cholesterol is essential for the normal development of the fetus, pregnant women, or women who might become pregnant, are advised not to take statins.

How Statins Work to Lower Cholesterol

Statins work by inhibiting an enzyme that is crucial to the manufacture of cholesterol by the body. (An enzyme is a specialized protein that helps to speed up a chemical reaction. For example, our digestive enzymes help speed up the breakdown of food into simple chemicals that can then be absorbed into the body.) Statins also increase the uptake of LDL cholesterol by the liver, another way in which they lower the blood level of cholesterol. The enzyme that is inhibited by statins works very early on in the synthetic pathway, (the synthetic pathway is like the assembly line in a factory; it is a set of chemical processes that occur inside cells as the body manufactures molecules it needs to survive). When this enzyme is inhibited the levels of other important molecules, such as coenzyme Q10 (more about that later), can also drop in people taking these medications.

Do I Need to Be on a Statin to Lower My Cholesterol?

So what should you do if your doctor informs you that you need to take a statin? The answer to whether or not you should follow that advice depends on your age, whether you are a man or a woman, and whether or not you have been diagnosed with atherosclerosis. Let me explain.

Atherosclerosis

Atherosclerosis is a form of hardening of the arteries in which plaque accumulates in the walls of arteries, eventually causing the opening of the vessels to narrow. When an artery becomes narrowed enough, the oxygen and nutrients carried by the blood cannot reach the organ supplied by that artery, starving it. For instance, the coronary arteries deliver blood to the heart. If the heart is not getting the amount of blood it needs—especially when it has to work harder, as it does during exercise or times of emotional stress—it is said to be ischemic. The term ischemia means a relative lack of blood supply. Hence, the terms ischemic heart disease (IHD), or coronary heart disease (CHD).

The symptom experienced by people whose hearts are being deprived of oxygen is called angina pectoris. Angina usually feels like a squeezing, burning, or pressure in the chest that is predictably brought on by exercise or emotional stress, and that goes away within about five minutes with rest, relaxation, or a medicine called nitroglycerin.

In addition to obstructing arteries to the point where blood flow is compromised, plaques can also rupture. A plaque that ruptures resembles an abscess or a boil in the wall of an artery. When the plaque material comes in contact with the blood flowing through that artery, the body tries to wall off this material by forming a blood clot (thrombus). If a clot forms over a ruptured plaque, blood flow through that artery can be completely interrupted, and the heart muscle downstream of the clot will die within a few hours if the circulation is not restored. Heart muscle damage from interruption of the blood supply is a myocardial infarction: a heart attack.

Risk Factors

We have a pretty good handle on the risk factors that make the development of atherosclerotic cardio-vascular disease (ASCVD) more likely. Only two of them can’t be modified: your age and your family medical history. You can lie about your age, but, of course, that doesn’t change it. And you might wish you had a different family and a different set of genes (I’ve always wanted to be taller), but we’re more or less stuck with the genes we were born with. All the other risk factors—such as smoking, high blood pressure, abnormal levels of blood fats, diabetes, inflammation, being sedentary, and obesity—are modifiable, avoidable, or treatable.

Risk Factors for Developing Atherosclerosis
CAN BE MODIFIED	CAN’T BE MODIFIED
Smoking	Age
Abnormal levels of cholesterol/triglycerides	Family history
High blood pressure
Diabetes
Obesity
Sedentary life style
Inflammation

The more of those risk factors you have, the greater your chance of developing ASCVD. But the guidelines focus mostly on cholesterol levels. The current guidelines for the prevention of ASCVD state that the “optimal” level of total cholesterol is under 200, the “optimal” level of LDL cholesterol is under 100, and the “optimal” level of triglycerides is under 150. The latter was recently changed to under 100, although 150 is still given as the upper limit of normal. Note that these are “optimal” levels: they are not the levels that everyone needs to reach, especially since for many people, given their unhealthy diet and lifestyles, such levels are achievable only with drugs.

Table 1. Optimal Levels of Blood Fats
Total cholesterol	Under 200
LDL cholesterol	Under 100
Triglycerides	Under 100

The guidelines that doctors are supposed to follow to prevent ASCVD say that your physician needs to determine the number of risk factors that you have, other than your LDL cholesterol level. Then, based on these, he or she classifies you as being at low, intermediate, or high risk. These other risk factors include age (forty-five years or older for men; fifty-five years or older for women), smoking, hypertension (blood pressure of 140/90 or more, or being on an antihypertensive medicine), low HDL cholesterol (under forty in a man, under fifty in a woman), and a family history of premature coronary heart disease in a male first-degree relative (father, brother, son) less than fifty-five years of age or in a female first-degree relative (mother, sister, daughter) less than sixty-five years of age. (For reasons we don’t understand, women, even at equivalent levels of risk, tend to develop ASCVD ten to fifteen years later than men do.)

Table 2. Major Risk Factors (Other Than LDL Cholesterol) That Modify LDL Goals*

• Cigarette smoking

• High blood pressure

• Low HDL cholesterol (under 40 in men, under 50 in women)

• Family history of premature coronary heart disease

• Age (forty-five and over in men, fifty-five and over in women)

* If HDL is 60 or more, this counts as a “negative” risk factor, and its presence allows you to subtract one risk factor from the total count. (Negative risk factor in this case means that high HDL cholesterol lessens the risk of developing plaque.)

For people who already have ASCVD or its equivalent (diabetes is considered a CHD risk equivalent), the “goal” should be to get the LDL cholesterol under 100. If someone has ASCVD and multiple other risk factors, then an optional goal is an LDL cholesterol under 70.

If a patient has zero to one risk factors—in other words, someone at low risk—then the LDL cholesterol goal is under 160, and the guidelines state that drug therapy should be considered if the LDL cholesterol is 190 or greater.

If someone has two or more risk factors, the LDL cholesterol goal is under 130, * and if someone has established vascular disease or diabetes, the LDL cholesterol goal is under 100. The guidelines state that the first line of therapy in any case is therapeutic lifestyle changes—more on that later in chapter 5.

Table 3. Three Categories of Risk that Determine LDL ...