First, the Part About Cholesterol and Heart Disease (February 9, 2016)
Almost everyone knows what cholesterol is by now. At the very least you probably remember that you heard the word “cholesterol” right before somebody tried to give you another prescription, so it must be Bad, m’kay. However, like everything else in creation, cholesterol is a lot more nuanced than that. And if you do indeed have High Cholesterol you should know that it can be managed, often very effectively, without one of those nasty, expensive, water-polluting prescription medications. Not that I’m biased or anything.
Cholesterol is a funny-looking little molecule (ok, all molecules are funny looking, but work with me here) that’s usually found in company with animal fats, which kind of gives it a bad rap right out of the gate. Be that as it may, it's essential in human biology as the starting point for sex hormones and all kinds of other important things. But when the amount of a particular variety of it in your bloodstream goes above a certain level, it becomes a matter of concern. That is because people with blood cholesterol above a certain level are more disposed to developing cardiovascular disease. Nothing nuanced about that.
So if and when your blood cholesterol gets above whatever level is currently trendy in the medical community that week, you will almost certainly be handed a prescription to lower it, and that prescription will almost always be a statin. The logic here is that statins lower the amount of cholesterol in your blood and thus, as a newly low-cholesteroled person, your chances of getting heart disease will decrease and your lifespan will be increased, right? Sadly, this is not necessarily true.
I say "sadly" because statins can be rough stuff. Statins can decrease your energy, cause kidney and liver injury and cognitive and sexual problems, increase the risk of muscle damage, and cause type 2 diabetes. So they would need to have a pretty strong upside to make you want to take them. Which for some people, they do. But not for everyone. And not even for everyone with high cholesterol. So what's going on here? Here's is what's happened with statins, and with cholesterol.
To actually know that a drug works to decrease heart disease and also to extend life expectancy (which are not necessarily the same thing), you would need to give it to a huge number of people and watch them for maybe ten to twenty years. That is very expensive as well as time consuming. If, on the other hand, you can assume that 1) cholesterol causes heart disease, and 2) lowering cholesterol in someone is the same thing as preventing heart disease, you can find out relatively quickly, testing many fewer people, whether you have a useful drug or not.
That's called using cholesterol as a "marker". Markers are used all the time in studying health and disease and in researching medications. And markers can be very useful. But once a therapy is found that affects the marker in the desired fashion, there are still questions left to be answered. One is, "do people who get this therapy actually get less disease?" Another one is, "do people who get this therapy live longer than people who don't get the therapy?" Those questions may never get asked at all if people are enamored enough with their new drug toy. And that is precisely the place where the lowering-cholesterol thing gets tricky.
Cholesterol itself is just one molecule, but it is packaged in a number of different forms in human blood. The one that everyone gets worked up about is low-density lipoprotein cholesterol (LDL-C for short). That is the one that supposedly causes heart disease and is targeted by statin drugs. There are several other varieties of cholesterol, plus some different molecules altogether, PLUS some conditions (like high blood sugar and inflammation) that are all probably bigger culprits in heart disease than LDL-C.
The majority of people who have heart attacks don't have high cholesterol. So we know that these other mystery factors must be very important. But to date they've been studied a lot less than has LDL-C, so we don't know much about them. Therefore they aren’t addressed in therapy or even measured most of the time.
So you can see how a medication that targets LDL-C would be leaving out these other potential causes of heart disease and therefore at best is already limited in its usefulness. But it is even more limited than all the above would suggest. Because IF you have already had a heart attack, taking a statin to lower your blood cholesterol past a certain point does seem to decrease the chance of a future heart attack. However, if you have NOT had a cardiovascular event of some type yet, you won’t live longer if you take a statin. Period.
Drug companies have been spending huge amounts of money for decades to try to prove that people will be healthier and live longer if EVERYONE takes statins. They have even proposed that statins should be put into public water supplies (although as I recall, that one didn't go over real big). But they have never been able to prove that people who’ve never had a stroke or heart attack will live longer if they take a statin drug. Never, ever, ever.
High cholesterol in the blood may indeed be something you would like to avoid, particularly if you are in a high-risk category for heart disease. But if you haven’t already had a heart attack, taking a statin will not lower your risk of death. That is such an absolute statement that I’m listing my authority for it right here:
Interestingly, it happens that the American College of Cardiology is largely unimpressed by this fact and in many circumstances your physician will press you to take a statin anyway. To my simple mind, then, here is a thought: If you don’t have heart disease yet, and your cholesterol is high, how about trying to lower it in some other fashion and get your doctor off your back, and maybe even do yourself some good?
Hence this newsletter, and the next as well (which will have specific measures you could take). If you are healthy but your LDL-C cholesterol is looking a little more robust than it ought to, and you're sure that you don't want heart disease to be part of your future, how about taking some other measures besides statins? I'll drink to that, and I will discuss it all next time.
--dr. diane holmes
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