Monday, July 18, 2011

STANDARD OF CARE ; LOWERING CHOLESTEROL

Raise cholesterol level is undoubtedly an important coronary risk factors. This risk factor is bi-directional, meaning that when you lower it, you also lessens the coronary risk. But it is important to note that cholesterol is not the only coronary risk factor. Large population study have shown that 40-50% of heart attacks occur in patients with normal cholesterol levels in the blood. But because we know that cholesterol levels can be reduced with dietary control or with drugs, and that lowering it helps to lower your coronary risk, it becomes important to lower it. This statement has spun the development of a billion dollar pharmaceutical industry. Each cholesterol lowering agent becomes a block buster, almost.
However, it is important too, to note that cholesterol is also required in the body, to built cell walls and also for good cellular metabolism, like the production of sex hormones, and brain function. So zero cholesterol in the body is also a bad option.
The main culprit in the generation of the cholesterol plaque ( atherosclerosis ), is the small dense LDL-cholesterol fraction. What I mean is that Cholesterol and LDL-cholesterol is not just a single moiety. There are subfractions, and some are very harmful ( like oxidised LDL-C ), while others are also harmless, large the large LDL-C.
Amongst the cholesterol, there are also the good cholesterol, the HDL-cholesterol, as opposed to the bad cholesterol, as we have said previously, the small dense LDL-C.
We can lower serum cholesterol, and also the LDL-C by one of two ways. This will form the bulk of this article.
We can lower cholesterol with the use of an effective life-style modification program, or with drugs.
I much prefer the life-style modification way, as it is free of side effects and it also saves money. However, it would require some discipline, and sacrifice. Of course, taking a pill a day, is so much easier, but it does cost money, and more importantly, exposes you to the potential of side effects.
I usually spend about 15 mins, counseling my patients on life-style modification, especially diet. Everyone with a raised serum cholesterol level or a raised LDL-cholesterol level, should embark on a life-style modification program. If you are at a higher coronary risk, you require stricter life-style modification, and if you have no other coronary risk factors. you require a less strict life-style modification program. As you know, the important coronary factors that we talk about will include raised LDL-Cholesterol, hypertension, cigarette smoking, and diabetes. Of course, anyone with a previous history of documented heart disease ( previous heart attacks, previous angioplasty or bypass surgery ) , are at increase risk of another heart attack, and they would be treated as high risk.
For those with two or less coronary risk factors, life-style modification with a good diet, is usually the way to go. Using of drugs should only be researved for those with diet resistant raised serum cholesterol level. A good cholesterol reducing diet includes avoiding all the food with raised cholesterol or other fats ( saturated fats ), which can be converted into LDL-C molecules. The cholesterol rich food, in our culture, would include egg yolk, coconut milk products like curries, most of the seafood, except fish. ( even amongst the fish family, there are some fish better than others ), fat pork, chicken skin, lards, and saturated fatty acid based cooking oil like ghee. The higher coronary risk you are, the stricter need for the diet. The lower the coronary risk, the less strict you need to be. The effectiveness of your diet program, can be regularly assessed with 3-6 monthly serum cholesterol checks. Failure to bring it down would require a stricter approach. A good exercise program also helps, not directly in lowering LDL-C, but indirectly, it protects by increasing HDL-C, and also losing weight, and maybe blood pressure. Fish oils does not lower LDL-C, but it is helpful, as it lowers triglyceride, and also thins the blood.
Drug therapy is the easier, and more effective way but it does involve cost, and the occasional patient does develop some side effects. The most commonly used and the most effective cholesterol lowering and clinically effective group of drugs are the "statins". They belong to a group of drugs called the HMG CoA reductase, simply meaning that it acts on a certain enzyme, to lower the production of LDL-cholesterol. They are a bit pricey, except those that have lost their patents. Their most common side effect is muscle aches and pains, something that is so common in the coronary risk age group, that I am sure its incidence is severely underestimated. Many of my patients ( by the way, they are about 60-75 years old ), have muscle aches and pains. So how do you tell them apart. Once the muscle aches and pains begin to affect their life-style, what they wish to do, I often stop the "statins" for 3 months to see if the aches and pains get less. Those that do, I deemed them as "statin intolerant", and take them off the "statins" and use an alternative, like ezetimide ( which is costly). Thsoe that are "statin intolerant" and financially tight, I change them to"hypochol", and chinese red yeast product, which does lower LDL-cholesterol and is quite reasonable price. I suspect this chinese red yeast rice, does contain some herbal "statin".
Who then should be started on a "statin"? Those who have 1. previous heart disease, 2. those who have 2 or more coronary risk factors, and whose LDL-C does not come down with a good life-style modification program.
Probably the most controversial part of cholesterol lowering, are the target levels. How low should we go? Here cardiologist are divided. Many ( myself excluded ) would like to lower it till an LDL-C of 75 mg%. Some like me would only lower it to an LDL-C of 100mg%. Of course, the former group reason that the lower the LDL-C level, the less coronary problem. This is true, except that I know that the lower I go, the more side effect I get, so that the little benefit from too lower an LDL-C may not be off-set by the risk of side effects, and also the cost. So that's my approach. I am also rather suspicious, that the clinical trials showing the benefit of very low LDL-C levels may be severely pharmaceutically biased.
The other controversial ( less than the former ), is the age to treat to target. I see some trying to lower cholesterol to low levels when the patient is 80 years old. I tell the family, that the clinical trials showing benefit at this age is so few, and the cost of keeping low LDL-C levels are so high ( human cost and money cost ), that at age 80 years. I would rather enjoy life. Heart attack, especially sudden cardiac death maybe a peaceful and good way to go too, if you know what I mean.
So let us follow a healthy life-style and be moderate in all that we do ( pun intended ). For those at high risk of heart disease, ie, 2 or more coronary risk factors, or previous heart disease, who are below 75years of age, please be strict, or stricter.
Prevetuion is always better then cure.

2 comments:

armouris said...

more info on cholesterol here - What is Cholesterol

shikender said...

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