Transcript Resident Report

Understanding and Controlling
Cholesterol
MKMG
MOUNT KISCO MEDICAL GROUP
Michael S.Wein, MD
Katonah Office
(914) 232-3135
Disclaimers, disclosures,
conflicts of interest, etc…

Absolutely none
Tonight’s theme:
Maximal treatment of high blood pressure
and high cholesterol, combined with
smoking cessation, if necessary, prevents
strokes and mini-strokes, and thus prevents
multi-infarct dementia.
Dementia
Alzheimer’s Disease (60%-80%)
 Vascular “multi-infarct” (20%-35%)
 Parkinson’s Disease (Lewy Body) (5%)
 Infectious

– Syphilis, AIDS, Creutzfeldt-Jacob, Lyme

Rare causes
– Pick’s Disease, Huntington’s

“Reversible” causes (10%)
-- B12 deficiency, hypothyroidism, Syphilis, Lyme,
NPH, sub-dural hematoma
Why it’s so important to control
your cholesterol

Good quality evidence links elevated cholesterol
with:
 Coronary heart disease (atherosclerosis,
heart attack, congestive heart failure)
 Stroke, TIAs,  multi-infarct dementia
 Kidney disease
 Peripheral vascular disease
 Carotid artery disease
Why it’s so important to control your
cholesterol

There is a continuous, graded relationship
between total cholesterol and coronary heart
risk.
4x risk
½x risk
Why it’s so important to control
your cholesterol

A meta-analysis of 38 clinical trials found
that for every 10% decrease in LDL
cholesterol, there is an 11% reduction in
total mortality*
*Circulation 1998 Mar 17;97(10):946-52.
Understanding the numbers….
Understanding the numbers…

Cholesterol is insoluble in blood. It needs
carriers called lipoproteins to transport it
throughout the body. These lipoproteins are
what we measure.
– LDL: The “bad” cholesterol
– HDL: The “good” cholesterol
– Triglycerides: Fat particles in blood
This is what
matters most
LDL – The “Bad” Cholesterol

LDL Cholesterol Levels
–
–
–
–
–
–
190 mg/dL and above -Very High
160 to 189 mg/dL - High
130 to 159 mg/dL - Borderline High
100 to 129 mg/dL - Near Optimal
Less than 100 mg/dL – Optimal
Less than 70 mg/dL – Very Optimal
If we wanted everyone to have “optimal” cholesterol, almost
all of us would be on medication.
Instead, we look at all the other risk factors, and personalize the
goal to the individual.
HDL - The “Good” Cholesterol

The higher your HDL, the lower your
cardiac risk.
–
–
–
–

Greater than 60 mg/dL - Optimal
40 to 60 mg/dL - Normal
30 to 40 mg/dL – Low
Less than 30 mg/dL – Very low
HDL has anti-atherogenic properties due to
reverse cholesterol transport, antioxidation,
blood vessel protection
Triglycerides – “Fats”

Elevated triglycerides are associated with
increased cardiovascular risk; however the
strength of this association is not as clear.

Must be measured after minimum 8-hour fast
–
–
–
–

Greater than 500 mg/dL -- Very high
200 to 499 mg/dL -- High
150 to 199 mg/dL -- Borderline
Less than 150 mg/dL -- Normal
Very high triglycerides can cause pancreatitis
Understanding the numbers…
Total cholesterol = LDL + HDL + 1/5 triglycerides
Patient A
Total -- 250
LDL -- 180
HDL -- 26
Trig -- 220
Patient B
Total -- 250
LDL -- 125
HDL -- 96
Trig -- 145
Take home point: “Total cholesterol” can be very
misleading; pay attention to what makes up the total
Treatment of high cholesterol

Lifestyle modification
– Diet, exercise, weight loss

Medications
– Statins should be first-line for almost everyone
– Fibrates, Niacin, Fish oils, Zetia/Vytorin
– Herbals?
Diet and Lifestyle
Diet




Use common sense!
Portion size and weight loss is key
Low saturated fat; low trans-fat (less than 7% of
total calories should be from saturated fat)
Low cholesterol (less than 200mg chol/day)
– One Egg McMuffin 260mg cholesterol
– One McDonalds Deluxe Breakfast 575mg chol

Ask for referral to a dietician
Dietary changes

Emphasize
– Colorful fruits and
vegetables
– Whole grains (wheat,
oats, barley)
– Lean meats and beans
– Omega 3s (fish, plant
sources
– Soy, nuts
– Balanced diet, portion
control

Avoid
–
–
–
–
–
Fried foods
Saturated fats
Trans fats
Simple sugars
Cheese, egg yolks,
beef, pork, poultry,
shrimp in moderation
– Fad diets
Exercise and weight loss
Goal of a minimum of 20 minutes of
aerobic exercise, at least three days per
week.
 This is one of the most effective ways to
raise HDL.

Case Study
19-year-old college student saw me for a
physical. Height 5’10”; Weight 270 lbs.
October 8, 2008
June 11, 2008
Total -- 230
LDL -- 155
HDL -- 38
Trig – 185
80 lb
wt loss
Total -- 165
LDL -- 92
HDL -- 64
Trig – 47
Glucose – 124
Glucose – 84
(Weight 270 lbs)
(Weight 190 lbs)
Medication Treatment
Medication Treatment - Statins

Statin drugs should be the cornerstone of
medication treatment for virtually all
patients with elevated cholesterol.

Statins are the only class of drugs to
demonstrate clear improvement in overall
mortality in primary and secondary
prevention of coronary heart disease.
Medication Treatment - Statins

The clear benefits of statins have been
demonstrated repeatedly in multiple wellcontrolled randomized clinical trials.

There are more quality studies showing
safety and clear benefits of statin drugs,
than with all other classes of cholesterol
lowering drugs combined.
Medication Treatment - Statins
– LDL: The “bad” cholesterol
– HDL: The “good” cholesterol
– Triglycerides: Fat particles in blood
This is what
matters most
Statins:
» Decrease LDL by 20-60%!
» Minimal increase in HDL (up to 10%)
» Modest improvement in triglycerides (15-35%)
Statins
– Lovastatin (generic for Mevacor) -1987

$4/month at Target/ Walmart
Least
potent
– Lescol XL (fluvastatin) no generic available - 1994
– Pravastatin (generic for Pravacol) -1991

$4/month at Target/ Walmart
– Simvastatin (generic for Zocor) - 1992
– Lipitor (atorvastatin) -no generic available - 1997
– Crestor (rosuvastatin) -no generic available - 2003
Most
potent
Other Medications

Gut absorption inhibitors
– Ezetimibe (Zetia)
» Moderate LDL reduction (≈ 20%)
» No effect on HDL
» No effect on triglycerides
– Vytorin (simvastatin plus ezetimibe)
Recent study (ENHANCE) showed no clinical benefit to
ezetimibe plus simvastatin, compared to simvastatin alone
Other Medications

Fibrates
– Gemfibrozil (Lopid)
– Fenofibrate (Tricor, Antara, Lofibra)
» Minimal LDL reduction (≈ 10%)
» Modest HDL improvement (up to 25%)
» Best for triglyceride reduction (up to 50%)
Other Medications

Niacin
– Niaspan, Slo-Niacin
» Minimal LDL reduction (≈ 15%)
» Modest HDL improvement (15-35%)
» Modest triglyceride reduction (25- 30%)
– Limited by tolerability (flushing)
Other Medications

Fish Oils (Omega 3’s)
– Lovasa (previously Omacor)
– Many OTC versions available
» No LDL reduction
» Minimal HDL improvement (3%)
» Moderate triglyceride reduction (up to 50%)
– Limited by GI side effects (oily stool)
Herbals and Alternative Treatments

Red Yeast Rice
– Used in Chinese medicine to
remove “blood blockages” dating
back to Tang Dynasty (800AD)
– May lower LDL ≈ 20%
– Active ingredient is lovastatin.
– Banned for sale in US by FDA, but may find it in
Asian markets, internet, etc.
– Problems with purity, contaminants, lack of
standardization.
Herbals and Alternative Treatments

Plant Sterols and Stanols
– Nature Made “Cholest-off”
– Many other products such as Promise-Active
spread, Promise-Active supershots, Benecol,
Minute Maid Heart-Wise, Rice Dream HeartWise beverages
» May reduce LDL slightly by inhibiting cholesterol
absorption
» There are NO clinical studies showing any benefit
» A study in mice showed harm
Herbals and Alternative Treatments

Soy (isoflavones)
– Has estrogen-like properties.
– Initial studies suggested benefit, but a more recent
systematic review showed only minimal benefit (3%
LDL reduction) from large quantities of soy.
– Feel free to substitute soy products for animal-derived
products because they are low in saturated fat, high
unsaturated fat, high fiber.
– But, don’t take soy with the intention that it will lower
your cholesterol.
Herbals and Alternative Treatments

Green Tea Extract
– A small randomized controlled trial showed a
statistically significant benefit, ≈10% LDL reduction

Garlic
– Recent large well-controlled trial showed no
benefit

Fiber (psyllium, oats, etc.)
– Recent randomized controlled study showed
statistically significant LDL reduction (≈10%)
– AHA recommends high fiber diet as “optional
dietary strategy to lower cholesterol”
MKMG
MOUNT KISCO MEDICAL GROUP
Michael S.Wein, MD
Katonah Office
(914) 232-3135