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Understanding and Controlling Cholesterol
MKMG MOUNT KISCO MEDICAL GROUP Michael S.Wein, MD Katonah Office (914)
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Disclaimers, disclosures, conflicts of interest, etc…
Absolutely none
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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.
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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
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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
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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
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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):
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Understanding the numbers….
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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
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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.
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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
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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
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Understanding the numbers…
Total cholesterol = LDL + HDL + 1/5 triglycerides Patient A Total LDL HDL -- 26 Trig Patient B Total LDL HDL -- 96 Trig Take home point: “Total cholesterol” can be very misleading; pay attention to what makes up the total
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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?
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Diet and Lifestyle
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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
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Dietary changes Emphasize Avoid 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
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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.
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Case Study 19-year-old college student saw me for a physical. Height 5’10”; Weight 270 lbs. Total LDL HDL -- 38 Trig – 185 Glucose – 124 (Weight 270 lbs) June 11, 2008 Total LDL -- 92 HDL -- 64 Trig – 47 Glucose – 84 (Weight 190 lbs) October 8, 2008 80 lb wt loss
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Medication Treatment
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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.
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Medication Treatment - Statins
The clear benefits of statins have been demonstrated repeatedly in multiple well-controlled 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.
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Medication Treatment - Statins
LDL: The “bad” cholesterol HDL: The “good” cholesterol Triglycerides: Fat particles in blood This is what matters most Decrease LDL by 20-60%! Minimal increase in HDL (up to 10%) Modest improvement in triglycerides (15-35%) Statins:
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Statins Lovastatin (generic for Mevacor) -1987
$4/month at Target/ Walmart Lescol XL (fluvastatin) no generic available Pravastatin (generic for Pravacol) -1991 Simvastatin (generic for Zocor) Lipitor (atorvastatin) -no generic available Crestor (rosuvastatin) -no generic available Least potent Most potent
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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
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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%)
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Other Medications Niacin Limited by tolerability (flushing)
Niaspan, Slo-Niacin Minimal LDL reduction (≈ 15%) Modest HDL improvement (15-35%) Modest triglyceride reduction (25- 30%) Limited by tolerability (flushing)
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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)
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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.
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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 Heart-Wise beverages May reduce LDL slightly by inhibiting cholesterol absorption There are NO clinical studies showing any benefit A study in mice showed harm
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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.
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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”
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MOUNT KISCO MEDICAL GROUP
MKMG MOUNT KISCO MEDICAL GROUP Michael S.Wein, MD Katonah Office (914)
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