Clearing the Cholesterol Confusion

This article is written in response to the opinions expressed in social media that any amount of cholesterol in blood is safe and good for the body. Such playing to the gallery with half-truths is dangerous and misleading.

Let us talk facts:

1.Yes, cholesterol is needed by the body for its various functions, but that amount need not be large. For example, when we are born our LDL cholesterol is as low as 40 to 50 mg%, but enough for our rapid brain and cellular development.

2. Yes, most of our body’s cholesterol is made in the liver. But liver can make more of it if we have faulty genes, or if our diet is high in trans-fats and saturated fats, and if we are sedentary or stressful.

3. Thus some people will have extra cholesterol beyond what is needed by the body

4. Is excess cholesterol harmful?

5. The simple answer is: anything in excess is harmful, just as

    Blood pressure is required for blood to flow in our arteries, but excess BP

(hypertension) is harmful.

    Sugar in blood is required for energy but excess sugar (diabetes) is harmful.

6. So, is high amount of cholesterol in blood related to heart disease?

7. A type of cholesterol in blood is called LDL cholesterol: in people in whom it is genetically high-above 190 mg%, it is the direct cause of fatty deposits in arteries called atherosclerosis- the basis of coronary heart disease

8. In most other people high cholesterol is a RISK FACTOR, increasing the chances of disease by interacting with other RISK FACTORS like hypertension, diabetes, smoking, physical inactivity, stress, lack of sleep, unhealthy diet etc.

9. These risk factors cause injury and inflammation of the inner linings of arteries making it sticky so that cholesterol can easily enter the linings and cause fatty deposits.

10. Higher the levels of LDL and other types of cholesterol, greater its ingress into the inflamed lining of arteries.

11. Studies done on more than 2 million people with over 20 million person-years of follow-up and over 1,50,000 cardiovascular events demonstrate a remarkably consistent association between the amount of LDL-C in the blood along with the duration for which the body is exposed to it, on one hand and the risk of atherosclerotic disease like coronary heart disease, on the other.

12. Conversely, reducing or correcting it (whether by lifestyle changes alone or along with cholesterol lowering drugs like statins) reduces the chances of disease, whatever the initial cholesterol levels.

13. These measures not only reduce cholesterol levels in the blood but also cause the fatty deposits in arteries to stabilize and even regress, which can REVERSE CORONARY DISEASE proven scientifically with intracoronary imaging. Hence, lifestyle measures and cholesterol lowering drugs like statins are a must in people who already have established coronary artery disease. These measures are also advisable in people who have not had disease but are estimated to be at higher risk.

Q: But how is it that some people with high cholesterol do not suffer from heart disease and some with average or low cholesterol suffer?

1.     Firstly, we should know that cholesterol is carried in blood by particles called lipoprotein particles. ‘Atherogenicity’ or likelihood of disease depends more on the number, size and characteristics of these cholesterol carrying particles rather than the amount of cholesterol in blood. But since in most people the amount of cholesterol and the number of particles correlate, and since the amount of cholesterol is more easily measurable, we estimate the risk by the amount of cholesterol in blood.

2.     Now, in some people if a large amount of cholesterol is carried by small number of large sized particles, even if their blood cholesterol levels are high they may escape heart disease because of small number of large size of particles or due to antiatherogenic factors like apoA1.

3.     Conversely, if in a person with low average cholesterol levels, if the cholesterol is carried by large number of small sized particles, he may still be more prone to disease due to large number of small sized particles.

4.     So, some people with low-average cholesterol levels may still get the disease and a few people with high cholesterol levels may not get the disease as explained above. But these are exceptions.

5.     Other reasons why people with average cholesterol levels may get heart disease is that other risk factors like hypertension, diabetes, diet, physical activity, sleep etc may play a major role causing inflammation of the artery and facilitating entry of cholesterol (whatever its level)

6.     In some other people high levels of other lipid particles in blood like Lp(a), remnant particles  etc may play a bigger role than LDL cholesterol.

So high cholesterol (especially high LDL cholesterol) is a risk factor increasing the chances of heart disease. How much is high and what is its desirable level varies from person to person. A conversation with your cardiologist can help you decide what is the desirable level for you and how to lower it to that level.

Cholesterol is needed by the body, but small amounts are sufficient.

Heart patients whose LDL cholesterol is brought down to such low levels with lifestyle changes or drugs or both, reduce their risk of heart disease remarkably. Although a small percentage can have side effects (which can be addressed to by their doctors) most tolerate the drugs well for life.

After all, millions of interventional cardiologists the world over wouldn’t all be wrong in trying to lower the cholesterol levels in their patients (with lifestyle changes and cholesterol lowering drugs if required) to help them prevent not only heart attacks and deaths but also procedures such as balloon angioplasty and bypass surgery.

 

At last……. an exercise study on normal weight diabetics!

Yes, most exercise studies on diabetics are on the overweight or obese diabetics with the recommendation to do 3–5 days per week of aerobic activity at moderate to vigorous intensity, achieving a minimal exercise duration of 150 min per week, and two to three sessions per week of strength training.

However, worldwide about 20% of diabetics are of normal weight (Body mass index <25 Kg/m²) and more so in India.

Not only that but compared with overweight/obese subgroups, people with a normal weight at diagnosis of type 2 diabetes are shown to have a higher risk of mortality. Thirdly, normal-weight type 2 diabetes is associated with sarcopenia or loss of muscle mass which mediates the elevated mortality risk in people with normal-weight diabetes compared with overweight people with type 2 diabetes.

So what exercise advice to give in such diabetics of normal to low weight?

In a study published in July 23 issue of the journal Diabetologia (STRONG-D study), 186 normal weight type 2 diabetics who did strength training exercises only, decreased their HbA1C levels significantly more than those doing aerobic exercise alone or a combination of aerobic and strength training.

Also, their muscle mass improved much more than the groups doing aerobic or combined exercises, which correlated with the decrease in HbA1C.

The moral of the story is that if you are a lean diabetic, concentrate on strength training with an aim to improve your muscle mass.

 

Medication for preventing coronary heart disease

Medications: The third step in preventing coronary heart disease

The first two steps we can take to prevent heart disease are some tests and a few lifestyle changes, which was discussed elsewhere. For many people, taking certain medications under a doctor's supervision to prevent heart disease is necessary and very beneficial. It can be called the third step to prevent heart attack.

The two main groups of drugs used to prevent heart disease are 1. Cholesterol lowering drugs like statins and 2. “blood thinners” like aspirin.

For people who are known to have coronary heart disease, for example people having angina or who have had heart attack, angioplasty  or bypass surgery, or brain stroke or disease in the arteries of the legs, both the above kinds of medicines are important and advisable for lifelong use under medical supervision. This is so that the chances of progression of disease or recurrence of untoward events like heart attack are minimized.

Those who have no symptoms of the disease but have a high coronary artery calcium score (done due to any reason) or if the heart arteries appear diseased in CT coronary angiography (again, done for any reason), it is better to take these two drugs as per the doctor's advice.

Statins not only lower LDL cholesterol in the blood but also stabilize or ‘shrink’ the fatty deposit in the arteries, preventing their erosion or rupture which can lead to a heart attack.

Other drugs which may be advised in addition to or instead of statins are ezetimibe, bempedoic acid, PCSK9 inhibitors, fibrates and ecosapent ethyl, which reduce cholesterol and triglycerides.

Drugs like low dose aspirin prevent clumping of platelets and clotting which can occlude arteries leading to a heart attack. Other “blood thinners” which may be advised in addition to or instead of aspirin are clopidogrel, ticagrelor and prasugrel.

What about people who have not had any sign of heart disease and are apparently healthy? Should they be taking these preventive drugs?

Well, statins may also be necessary for those who have no symptoms of heart disease, but who are at high risk of developing heart disease in the future.

So how do you know in seemingly healthy people who are more likely to develop heart disease in the future?

The likelihood of future heart disease in apparently healthy people depends on their risk factors and certain physical conditions. Doctors take these two factors into consideration or use certain formulas (risk scores) to predict how likely people are to have a heart attack in the next 10 years. All risk scores (Google ‘CVD risk stratification in Indians’) are estimated on the basis of how many and how severe the risk factors are in us. As mentioned earlier the known factors are hypertension, diabetes, cholesterol, smoking, obesity, lifestyle, improper diet, family history of heart disease etc.

If the chance is more than 20% according to the risk scores, or if if LDL cholesterol is over 190 mg% or if there is long standing diabetes, then taking a statin (of course, in addition to healthy lifestyle choices) may have more benefits than risks.

If the likelihood of having heart disease on the basis of risk scores is less than 5%, then only lifestyle changes may suffice to prevent the disease.

If the chance is between 5% and 20%, the decision to take the drug requires further tests, such as coronary artery calcium score, doppler test of femoral and carotid arteries, BP difference between all 4 limbs and blood tests like apoB, hs CRP, LPA, troponin, etc. Other physical conditions like lung or joint disease, kidney disease, HIV, high blood pressure, diabetes during pregnancy in women or a history of premature birth or lack of breast feeding may put one at higher risk so that it may be beneficial in these people also to take a statin under medical guidance.

The decision to start a statin should be based on discussion with the doctor and after understanding its benefits versus harm for the individual.

Other ‘preventive’ drugs are all medications to keep blood pressure and sugar under control. Of particular preventive benefits are certain medications such as SGLT2 inhibitors and GLP1 agonists for diabetes, RAAS blockers for hypertension, beta blockers for hypertension with angina, or after a heart attack or heart failure.

Should seemingly healthy people take aspirin for life to prevent heart attacks?

It was a popular belief that everyone should take baby aspirin to prevent heart attacks because heart attacks are caused by blood clots in addition to fatty deposits and aspirin prevents these clots from forming. But after a few years of research on many people, it was found that along with the benefits of aspirin, there is also adverse effect of bleeding. In people who have a history of bleeding or are over 70 years of age, the risk of bleeding outweighs the benefits of preventing heart attacks, so the net harm is greater. So, taking aspirin over the counter or without medical advice is inappropriate for such people. Yes, it can be taken to prevent heart attacks (not to prevent death) in people younger than 70 with risk factors for heart disease or with long-standing diabetes, but after consulting a cardiologist.

Thus, almost 90% of heart attacks can be avoided by 3 steps: 1. certain tests, 2. certain lifestyle changes and 3. taking certain medications as advised by the doctor. Despite all these efforts, if a heart attack (the remaining 10%) still occurs, the damage caused by the heart attack can be avoided by immediately recognizing the symptoms and getting prompt treatment.

 

 

 

 

Key Points on low dose aspirin

Yesterday some of my more well informed and alert patients and friends drew my attention to a newspaper report of the US preventive task force’s latest recommendation about low dose aspirin. This short write up is pertaining to the same so that there is clarity in minds of people.

1.       Clotting and bleeding are opposite phenomena. Agents which prevent clotting can cause bleeding. Aspirin is one such agent.

2.       There are two groups of people for whom preventive therapy with low dose (LD) aspirin is applicable.(Low dose which is less than 100mg has been shown to have same benefits as full dose of 325 mg, but with the benefit of less bleeding.)

3.       One group is composed of those who already have evidence of arterial disease such as a heart attack, angina, angioplasty, bypass surgery, ischemic brain stroke or arterial disease of the limbs.

4.       For these people, life-long LD aspirin (or another antiplatelet drug like clopidogrel) is HIGHLY advisable because the benefit in terms of preventing another clotting event like a heart attack far outweighs the risk of bleeding in the gut or the brain-the most important risk with aspirin. This is called secondary prevention.

5.       The other group of people is composed of those who are apparently healthy and wish to prevent heart attacks or strokes in future, which is called primary prevention.

6.       Some years back, the popular notion was that LD aspirin should be given to all above 40 years to prevent a heart attack. This was not based on scientific evidence, but from observation and impression gathered from population.

7.       In the last few years came hard evidence in form of placebo controlled, randomized trials with aspirin which showed that for primary prevention, the risk of bleeding may outweigh the benefit with LD aspirin.

8.       Hence in 2019 American College of Cardiology & American Heart Association recommended that LD aspirin for PRIMARY PREVENTION is not advisable for people above age 70 or ANYONE at high bleeding risk.

9.       But they said LD aspirin MAY BE advisable for primary prevention in people between ages of 40 and 70 who are at high cardiovascular disease risk (such as people with family history of premature heart disease, people with hypertension, diabetes, high cholesterol, smokers, obese etc) and low bleeding risk, to prevent heart attacks and colorectal cancer. It may also be recommended for people who already are on LD aspirin without side effects.

10.   The current US task force’s recommendation is almost the same as the 2019 recommendation by ACC-AHA except that the upper age limit is brought down to 60 and prevention of colorectal cancer is no longer a reason for preventive therapy with LD aspirin. 

11.   These are general recommendations for the population. At the individual level, shared decision making with your cardiologist is recommended after weighing your probability of benefit against your risk of bleeding with LD aspirin.

12.   Lastly, one group of patients that is not covered by the above scientific bodies is people without any symptoms but with fatty deposits in their heart, brain or leg arteries as shown by tests like coronary artery calcium score, coronary CT angiography, doppler showing plaques in carotid arteries or BP in legs lower than that in arms.

13.   Such people (for example with coronary artery calcium score more than 100 and) at high risk may be well advised LD aspirin for prevention. Again, shared decision making with your cardiologist is advisable after discussing the risk-benefit issues.

 

Doc, are pills prescribed for BP and cholesterol, habit forming? Is it true 

that once started they cannot be stopped?

Well, the answer is that they are not habit forming (in the sense some drugs acting on the mind are), although if they benefit you in the long term helping you to prevent heart attacks and brain strokes, they are a good “habit” to form!

If BP and cholesterol levels are not at desirable levels as per your risk profile, and if your cardiologist feels you that in addition to the lifestyle changes you have instituted, pills are also required to control their levels to reduce the risk of heart attack or brain strokes, then it may be advisable to take them as long as your cardiologist feels you should take them, which in many cases could be lifelong. But that will drastically cut your risk of heart attack or brain strokes in future, if taken as advised.

About stopping them once started? Well it depends on your risk of having heart attacks in future (which depends on your lifestyle and risk factors like family history, presence of hypertension, diabetes, cholesterol etc.), and your response to changes in lifestyle and drugs.

For example, if your BP comes down with lifestyle measures such as weight reduction, salt and alcohol restriction, doing regular exercise, sleeping well and increasing fruits and vegetables in diet, your pills can be tapered gradually over weeks and months keeping a watch over your BP, lest it should go up again.

If it remains normal on repeated checking despite tapering and stopping pills, one can do away with the BP pills. If after tapering and stopping pills, BP rises again, then the pills will have to be reinstituted.

In case of cholesterol pills, commonest of which are called statins, research has found tremendous benefits with their use in people at high risk, for example people who are known to have coronary artery disease or people with multiple risk factors alluded above.

But again, in people with low or intermediate risk, if cholesterol levels plummet with intensive lifestyle changes, these pills can be stopped, and lipid levels checked again at regular intervals to see if they remain low. If they rise again, one may have to reinstitute the drugs at the advice of one’s cardiologist after a risk-benefit discussion.

One caveat to all the above is that there are certain drugs which are dangerous to stop suddenly. For example, a class of drugs called betablockers or a drug like clonidine, if stopped suddenly can cause rebound hypertension (to levels higher than those before drug was started) and rarely even cause heart attacks. Hence if they are to be stopped, it should only be done gradually under the guidance of your cardiologist.

As far as cholesterol lowering drugs (like statins) are concerned, stopping them suddenly in a person having underlying coronary disease may increase his/her risk of worsening his/her condition. Hence again, if one wants to stop or alter them, it should be done under a cardiologist’s guidance.

Thus, BP drugs and Cholesterol drugs are a good “habit” to form if they are required to control your BP and cholesterol levels which will benefit you in the long term to prevent heart attacks and brain strokes. If you are at low or intermediate risk and if BP and cholesterol are well controlled with healthy lifestyle and habits, then stopping or altering drugs is possible but not without medical guidance.

 

 

 

 

 

 Purpose in life, sleep and walking speed

A page from my book “Romancing the Heart” (available on Amazon)

·         There is a curious relationship between having a purpose in life, your walking speed and your sleep.

·         Not only are they inter-related, but they all also independently impact health.

·         This is especially important for those above 55 or 60 years of age, when both walking speed and sleep start being affected, commonly.

·         Studies have found that if you have a higher purpose in life, a pet project or an exciting reason to get up in the morning, you are more likely to have better sleep. Also, in that case, your walking speed does not diminish as you age and you may stay more physically fit.

·         Now the interesting thing is that although a higher purpose in life improves walking speed and sleep, both these latter are also affect each other: if you walk better, you sleep better and if you sleep better you can walk better.

·         To top it all, the three, each by independent mechanisms, impact health, for example walking speed by cardiorespiratory fitness, purpose in life by psycho-neuro-immune pathways and cell repair with better sleep.

·         Finally, the silver lining is that both can change for the better. Walking speed can be improved with practice and purpose in life can be cultivated. These measures can improve sleep and overall health.

·         Volunteering, learning new things, cultivating relationships and hobbies and interests can be important ways for increasing one’s sense of meaning in life. This protects against many negative health and psychological outcomes, especially of older age.

·         Hence, don’t wait. Increase your walking speed, but first better find out something exciting to do which fills a need and fulfils yourself! It will help you sleep better, walk faster.

 

New motherhood and reducing long term risk of cardiovascular disease

When new motherhood should get help from three different kinds of doctors:

The most common risk factors to cause cardiovascular disease (CVD) are the simple seven-smoking, physical inactivity, overweight, diet, blood glucose, cholesterol, and blood pressure.

In pregnant females, added to these risk factors are problems related to pregnancy such as preeclampsia, gestational hypertension, preterm birth, and intrauterine growth restriction, which increase CVD risk several fold and represent an opportunity to identify at-risk women and prevent or reduce future CVD like chronic hypertension and coronary heart disease.

Hence, the months after childbirth in women who have had complicated pregnancies are the period of great opportunity when a close collaboration between obstetricians and cardiologists can prevent or retard future development of CVD in such women.

When does the pediatrician come in?

Breastfeeding is recommended for infant nutrition across the world. According to the American Academy of Pediatrics, babies who are breastfed for at least 6 months are less likely to be overweight, and the duration of breastfeeding is inversely related to the risk of obesity. The incidence of type 2 and type 1 diabetes mellitus are less by 40% and 30% respectively, in breastfed infants. A likely mechanism in the development of type 1 diabetes mellitus is the infant’s exposure to cow milk β-lacto globulin, which stimulates an immune-mediated process cross-reacting with pancreatic β -cells. Additional benefits include boosting the baby’s immune system and lowering the risk for asthma and sudden infant death syndrome.

But those are the benefits for the child. What about the mother?

A large prospective study in nearly 300 000 women in China showed that a history of breastfeeding was associated with a 10% lower risk of CVD later in life. Moreover, each additional 6 months of breastfeeding was associated with a further 3% to 4% lower CVD risk.

The mechanism could be that breastfeeding increases metabolic expenditure by an estimated 480 kcal/d and may enable a more rapid reversal of metabolic changes in pregnancy, including improved insulin sensitivity and lipid metabolism and greater mobilization of fat stores.

Serum triglycerides, low-density lipoprotein cholesterol, and very low-density lipoprotein cholesterol all increase in the last trimester of pregnancy.

Lactation contributes to rapid reversal of these changes through excretion of triglycerides and cholesterol in milk. In addition, longer breastfeeding duration has been associated with a lower maternal risk of metabolic syndrome, hypertension, and diabetes mellitus later in life.

Besides, a 2019 longitudinal study of more than 100 000 Australian women found that ever breastfeeding was associated with lower maternal risk of CVD hospitalization and mortality compared to never breastfeeding.

Breastfeeding may be especially important for women who develop pregnancy complications such as preeclampsia, because we know that these conditions increase lifetime risk of CVD.

Thus, new motherhood (with pregnancy complications as mentioned) is the sacred place where Pediatricians Obstetricians and Cardiologists should meet. It will help the mother, the baby and the society.