Posts Tagged ‘Statin’
Some Suggestions
The data shows that a Quarter Pounder contains 19 g of total fat and 1g of trans fat. If you add cheese and a small milk shake you get 36g of total fat and 2.5 g of trans fat. They don’t call it a “Whopper” for nothing. The scientific data shows that by ingesting a dose of statin (except pravastatin), you can actually offset the “balance” of the meal. The question — is this a valid way to eat? Shouldn’t we eat better and take less medication?
It’s not just the trans fat and total fat. The new target is removing all the salt from food. Good luck with that. How many years did it take for women to get the vote? What good does it do if we take the salt out of the food if we just provide it back at the condiment counter? That’s where the ketchup comes in. Most people don’t realize the salt content of ketchup and how bad it is for you if you have hypertension, congestive heart failure (CHF) or coronary disease.
Diet is felt to affect cardiovascular risk in perhaps more than a dozen ways. Clearly, it is involved with diabetes and the development of that condition. Diabetes has a profound effect on coronary disease and coronary disease is right up there with renal failure as a mode of death in the diabetic patient.
It’s not just what we eat, it’s the amount. I have blogged in the past about the effects of obesity on our population and the chaos it will soon cause in the healthcare system. The majority of us just eat too much and we often don’t eat the right things. The recommendation is to avoid processed foods, and try to eat as close to basic as possible. This is the opposite of “fast food” although much has changed. What has not changed is that when MacDonald’s offers us a choice of a salad or a Big Mac, we choose the Big Mac. Taking a statin at that point is akin to buying a pack of cigarettes and getting an inhaler with it for your lung disease.
We need to be more proactive as to diet. This is starting in school lunches and in some fast food establishments. The “market” still wants the “bad” and I don’t see it changing soon. Clearly, it seems to be getting worse. We even have TV shows now like the Biggest Loser which highlights the losing of massive amounts of weight. Wouldn’t it be better if you didn’t get that way in the first place?
There is not much excitement here. If you have or want to prevent heart disease, you need to eat better - much better. If after that, you still have elevated cholesterol you need to take statins IN ADDITION TO DIET. If you have coronary disease, you need to eat better and take statins.
What is it going to take to get this message across?
They Are Kidding…Right?
On August 15, 2010 in the American Journal of Cardiology, a group of cardiologists reported on a concept and in doing so, unleashed a firestorm of controversy. At first, lay people and physicians didn’t know if they were kidding and then became angry at the proposal.
What was this heresy? These British cardiologists proposed that next to the ketchup, salt and mayonnaise at the condiment counter there should be a container of ground up statin that people would sprinkle on their burgers, and by doing so would alleviate the damage they were doing by eating the burger.
Where does one start discussing this? First, I would like to note that in Great Britain you can buy a statin, Zocor (simvastatin), over the counter in doses of 10mg. Much like you can buy Zantac here. I applaud them for that. However, most of the science says that you need 20mg to obtain the benefit of simvastatin. Again, I will mention that we believe the benefit is an anti inflammatory effect of the statin on the cholesterol. And that effect lowers the of risk of further cardiac problems.
But where does the inflammatory effect come from? Most people believe it comes from our diet. There are some individuals that feel it comes from infection, but that line of investigation has not led us to any solutions. It seems to be our diet. Interesting sociologic data from many years ago, and you will have to excuse me because I cannot quote it exactly, shows that when you take the native Japanese population and move them closer to New York, the closer you get to New York, the higher incidence of heart disease you have. Indeed, in any population of people who eat like us, the increase in coronary disease is noticeable. The latest example is in China.
Come on people we are all basically the same genetic code. How come we have such a high level of disease in New York but such a low level of disease in Africa? “It’s the diet, stupid”, to paraphrase a recent president who, by the way, lost a great deal of weight for his daughter’s wedding. The genetic component of coronary disease seems to be the turning on and off of genes when they are exposed to a western diet full of all the things we love to eat. This, coupled with cigarette smoking and high blood pressure, seems to be enough.
My 35 year old patient, with multi vessel disease, that I admitted after an anterior myocardial infarction says “hello”. We are seeing this illness at a younger and younger age.
What are we to do…
Everything You Wanted to Know About Sex But Were Afraid to Ask
My apologies to Dr. David Reuben, who wrote the book by this title in 1971, for stealing his title. Yes it seems a long time ago that people thought this was so controversial. I guess that’s what the Internet has done. People are definitely more informed. Or are they?
It turns out that we cardiologists are not doing a very good job giving advice on resuming sexual activity after sustaining a myocardial infarction, and it seems we must do better. I must plead guilty as charged. I spend considerable time telling people to take Plavix and aspirin, and to increase their statin dose, but honestly, it never really occurred to me to tell people about sex.
A study known as TRIUMPH or Translational Research Investigating Underlying Disparities in Recovery from Acute Myocardial Infarction: Patients’ Health Status was presented at the recent American Heart Association meeting in Washington D.C. It is quite an eye opener. Only 46% of the men and 34% of the women received post discharge instruction when to resume sexual activity. Less than 40% of men and less than 20% of women had any discussion at all about sex with any of their physicians in the year after a heart attack.
The study found that 67% of men resumed sexual activity, but only 40% of women in that year. These data were controlled for variables such as age and partner status, so the reasons for the disparity is not that women were single or uninvolved more than men. It seems that there is significant room for improvement.
This lack of information clearly needs to be improved, and to become a greater focus of our discussion with patients. It may help to start a program with a trained health care professional who would take the lead in providing information and guidance with a doctor’s order. This is similar to other outreach programs that have been successful. Cardiac rehab may also serve as a place to provide this kind of information. Offices visits post hospitalization also seem like a place to start the conversation, as these areas are generally more private than a patient room or other hospital settings.
It’s time to help “Stella get her groove back.” It’s just one more example that we must care for the whole patient not just the lipid levels. Thanks to these researcher’s for pointing out an area of much needed improvement.
Why We Need to be in ACCORD
My favorite reason for doing research is that I have been fascinated in the past twenty years by what we as doctors think is the correct way to treat patients only to find that when we study the condition, we just have it all wrong. I know that that doesn’t fit with the perception that we “know it all” and can always make “the right call,” but it keeps us real. We can only use the data that is driven by the studies in our attempt to treat patients to the best of our ability. We want the best outcomes for patients.
Diabetes is a terrible chronic illness and it goes hand-in-hand with atherosclerotic disease in all of its forms, stroke, myocardial infarctions, and amputations. It is a terrible scourge, and I deal with it on a daily basis.
In an attempt to determine optimal diabetic treatment, a study was devised and named ACCORD or Action to Control Cardiovascular Risk in Diabetes. This study used the same group of patients to answer three questions that seemed simple at the time.
1. Is intensive gylcemic (sugar) control better?
2. Is lower blood pressure better?
3. Is better lipid control better?
To answer the first question patients were divided into two groups and one was treated in the standard way and one was forced to lower hemoglobin A1C levels than previously recommended. Hemoglobin A1C is a long-term measure of gylcemic control.
To answer the second question, the groups were targeted to a systolic blood pressure of 140 or forced to a systolic of 120. This was unblinded i.e. the investigators knew what they were supposed to do.
To answer the third question the groups received either a statin or a statin and a fenofibrate.
See if you can guess the results. The answer next time…
Drugs: From A(pproval) to Z(etia)
I was discussing the use of the drug Zetia before I was interrupted by the FDA so I will now return to that. Zetia is a novel compound that is used either with or without a statin. Zetia works on the lining of the small intestine to block the absorption of cholesterol from the intestines. It is not fully understood why all cholesterol in the body is transported into the intestines to then be reabsorbed into the circulation. It is this step that Zetia blocks and it is how cholesterol is lowered. The cholesterol synthesis pathway is “feedback,” i.e. if the level of cholesterol is lower than the body thinks it needs, the liver will produce more cholesterol. It is this step that the statin blocks so that the combination of a statin and Zetia is a very effective way to lower LDL cholesterol.
This is how Zetia got its approval. It dates back to 2006, when any drug was approved by the FDA if it simply lowered cholesterol. Now the FDA requires a proven clinical benefit before granting approval. Zetia has yet to prove that clinical benefit and that is where the controversy arises. In fact–in every study to date–although the combination of Zetia and statin lowers cholesterol, the endpoints for the study have not been met and Zetia always does worse.
My particular problem with the combination is that it is often used to lower the amount of statin used in individual patients. We have large amounts of data that indicate the higher the dose of statin one takes, the better the outcomes. LDL lowering is an easily measured end point for something we can not easily measure. We don’t care what the level of LDL really is; we want to obtain the lowering of death, myocardial infarction and unstable angina-which is what statins do. The higher the dose of statins, the more effect they have on decreasing the endpoints that truly matter.
Two studies have now used the endpoint of the increase in plaque buildup in the carotid arteries. ENHANCE reported in 2008 and now ARBITER-6 released this past month. Neither study involved clinical endpoints. They did not evaluate whether fewer strokes or myocardial infarctions occurred. They simply determined which group had a better imaging response. In both studies, Zetia failed. In ENHANCE against simvastatin alone and in ARBITER-6 niacin performed better than the combination.
Physicians are divided on how to use this drug. A panel of FDA experts declared that it should be used “as a last resort” to lower cholesterol. The real proof will have to wait until 2013. That is when the results from IMPROVE-IT will most likely be released at the American College of Cardiology meeting. This study started several years ago will randomize 18,000 patients and follow them for a minimum of two and one-half years. The primary end points are death and myocardial infarction. The study uses simvastatin vs. the combination of Zetia and simvastatin.
Your particular use of Zetia is defined by your needs and your doctor’s advice. This is the backdrop against which this drug is prescribed. As always you should discuss your medication use with your physicians.
About the Institute
Browse by Category
- Acute Coronary Syndrome (14)
- Adult Stem / Cell Treatment (10)
- Angioplasty (4)
- Aortic Aneurysms /Stents / Grafts (13)
- Atherosclerotic Heart Disease (12)
- Atrial Fibrillation (11)
- Cardiac Imaging (4)
- Cardiac Surgery (19)
- Carotid Disease (7)
- Cholesterol (51)
- Chronic Angina (13)
- Clinical trials (3)
- Coronary Artery Disease (34)
- diabetes (15)
- Heart Failure (30)
- High Blood Pressure (22)
- Myocardial Infarction (36)
- Pacemaker / AICDs (9)
- Peripheral Artery Disease (5)