Understanding and Controlling Understanding and Controlling CholesterolCholesterol

MKMGMKMG

Michael S.Wein, MDMichael S.Wein, MDKatonah OfficeKatonah Office

(914) 232-3135(914) 232-3135

MOUNT KISCO MEDICAL GROUPMOUNT KISCO MEDICAL GROUP

Disclaimers, disclosures, Disclaimers, disclosures, conflicts of interest, etc…conflicts of interest, etc…

Absolutely noneAbsolutely none

Tonight’s theme:Tonight’s theme:

Maximal treatment of Maximal treatment of high blood pressurehigh blood pressure and and high cholesterolhigh cholesterol, combined with , combined with smoking cessationsmoking cessation, if necessary, prevents , if necessary, prevents strokes and mini-strokes, and thus prevents strokes and mini-strokes, and thus prevents multi-infarct dementia.multi-infarct dementia.

DementiaDementia Alzheimer’s Disease (60%-80%)Alzheimer’s Disease (60%-80%) Vascular “multi-infarct” (20%-35%)Vascular “multi-infarct” (20%-35%) Parkinson’s Disease (Lewy Body) (5%)Parkinson’s Disease (Lewy Body) (5%) InfectiousInfectious

– Syphilis, AIDS, Creutzfeldt-Jacob, Lyme Syphilis, AIDS, Creutzfeldt-Jacob, Lyme Rare causesRare causes

– Pick’s Disease, Huntington’sPick’s Disease, Huntington’s ““Reversible” causes (10%)Reversible” causes (10%)

-- -- B12 deficiency, hypothyroidism, Syphilis, Lyme, NPH, sub-dural B12 deficiency, hypothyroidism, Syphilis, Lyme, NPH, sub-dural hematomahematoma

Good quality evidence links elevated cholesterol Good quality evidence links elevated cholesterol with:with:

Coronary heart disease (atherosclerosis, Coronary heart disease (atherosclerosis, heart attack, congestive heart failure)heart attack, congestive heart failure)

Stroke, TIAs, Stroke, TIAs, multi-infarct dementia multi-infarct dementia Kidney diseaseKidney disease Peripheral vascular diseasePeripheral vascular disease Carotid artery diseaseCarotid artery disease

Why it’s so important to control Why it’s so important to control your cholesterolyour cholesterol

Why it’s so important to control Why it’s so important to control your cholesterolyour cholesterol

There is a continuous, graded relationship There is a continuous, graded relationship between total cholesterol and coronary heart between total cholesterol and coronary heart risk.risk.

4x risk

½x risk

A meta-analysis of 38 clinical trials found A meta-analysis of 38 clinical trials found that for every 10% decrease in LDL that for every 10% decrease in LDL cholesterol, there is an 11% reduction in cholesterol, there is an 11% reduction in total mortality*total mortality*

*Circulation 1998 Mar 17;97(10):946-52.

Why it’s so important to control Why it’s so important to control your cholesterolyour cholesterol

Understanding the numbers….Understanding the numbers….

Understanding the numbers…Understanding the numbers…

Cholesterol is insoluble in blood. It needs Cholesterol is insoluble in blood. It needs carriers called lipoproteins to transport it carriers called lipoproteins to transport it throughout the body. These lipoproteins are throughout the body. These lipoproteins are what we measure.what we measure.

– LDL: The “bad” cholesterolLDL: The “bad” cholesterol– HDL: The “good” cholesterolHDL: The “good” cholesterol– Triglycerides: Fat particles in blood Triglycerides: Fat particles in blood

This is what matters most

LDL – The “Bad” CholesterolLDL – The “Bad” Cholesterol LDL Cholesterol LevelsLDL Cholesterol Levels

– 190 mg/dL and above -190 mg/dL and above -Very HighVery High– 160 to 189 mg/dL - 160 to 189 mg/dL - HighHigh– 130 to 159 mg/dL - 130 to 159 mg/dL - Borderline HighBorderline High– 100 to 129 mg/dL - 100 to 129 mg/dL - Near OptimalNear Optimal– Less than 100 mg/dL – Less than 100 mg/dL – OptimalOptimal– Less than 70 mg/dLLess than 70 mg/dL – Very Optimal – 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” CholesterolHDL - The “Good” Cholesterol The higher your HDL, the lower your cardiac risk.The higher your HDL, the lower your cardiac risk.

– Greater than 60 mg/dL - Greater than 60 mg/dL - OptimalOptimal– 40 to 60 mg/dL - 40 to 60 mg/dL - NormalNormal– 30 to 40 mg/dL – 30 to 40 mg/dL – LowLow– Less than 30 mg/dL – Less than 30 mg/dL – Very lowVery low

HDL has anti-atherogenic properties due to reverse cholesterol transport, HDL has anti-atherogenic properties due to reverse cholesterol transport, antioxidation, blood vessel protectionantioxidation, blood vessel protection

Triglycerides – “Fats”Triglycerides – “Fats” Elevated triglycerides are associated with Elevated triglycerides are associated with

increased cardiovascular risk; however the increased cardiovascular risk; however the strength of this association is not as clear.strength of this association is not as clear.

Must be measured after minimum 8-hour fastMust be measured after minimum 8-hour fast

– Greater than 500 mg/dL -- Greater than 500 mg/dL -- Very highVery high– 200 to 499 mg/dL -- 200 to 499 mg/dL -- HighHigh– 150 to 199 mg/dL -- 150 to 199 mg/dL -- BorderlineBorderline– Less than 150 mg/dL -- Less than 150 mg/dL -- NormalNormal

Very high triglycerides can cause pancreatitisVery high triglycerides can cause pancreatitis

Understanding the numbers…Understanding the numbers…

Total cholesterol = LDL + HDL + 1/5 triglyceridesTotal cholesterol = LDL + HDL + 1/5 triglycerides

Patient A

Total -- 250LDL -- 180HDL -- 26Trig -- 220

Patient B

Total -- 250LDL -- 125HDL -- 96Trig -- 145

Take home point: “Total cholesterol” can be very Take home point: “Total cholesterol” can be very misleading; pay attention to what makes up the totalmisleading; pay attention to what makes up the total

Treatment of high cholesterolTreatment of high cholesterol

Lifestyle modificationLifestyle modification– Diet, exercise, weight lossDiet, exercise, weight loss

MedicationsMedications– Statins should be first-line for almost everyoneStatins should be first-line for almost everyone– Fibrates, Niacin, Fish oils, Zetia/VytorinFibrates, Niacin, Fish oils, Zetia/Vytorin– Herbals?Herbals?

Diet and LifestyleDiet and Lifestyle

DietDiet Use common sense!Use common sense! Portion size and weight loss is keyPortion size and weight loss is key Low saturated fat; low trans-fat (less than 7% of Low saturated fat; low trans-fat (less than 7% of

total calories should be from saturated fat)total calories should be from saturated fat) Low cholesterol (less than 200mg chol/day)Low cholesterol (less than 200mg chol/day)

– One Egg McMuffin 260mg cholesterolOne Egg McMuffin 260mg cholesterol

– One McDonalds Deluxe Breakfast 575mg cholOne McDonalds Deluxe Breakfast 575mg chol

Ask for referral to a dieticianAsk for referral to a dietician

Dietary changesDietary changes

EmphasizeEmphasize– Colorful fruits and Colorful fruits and

vegetablesvegetables– Whole grains (wheat, Whole grains (wheat,

oats, barley)oats, barley)– Lean meats and beansLean meats and beans– Omega 3s (fish, plant Omega 3s (fish, plant

sourcessources– Soy, nutsSoy, nuts– Balanced diet, portion Balanced diet, portion

controlcontrol

AvoidAvoid– Fried foodsFried foods– Saturated fatsSaturated fats– Trans fats Trans fats – Simple sugarsSimple sugars– Cheese, egg yolks, Cheese, egg yolks,

beef, pork, poultry, beef, pork, poultry, shrimp in moderationshrimp in moderation

– Fad dietsFad diets

Exercise and weight lossExercise and weight loss

Goal of a Goal of a minimumminimum of 20 minutes of of 20 minutes of aerobic exercise, at least three days per aerobic exercise, at least three days per week. week.

This is one of the most effective ways to This is one of the most effective ways to raise HDL. raise HDL.

Case StudyCase Study 19-year-old college student saw me for a 19-year-old college student saw me for a

physical. Height 5’10”; Weight 270 lbs.physical. Height 5’10”; Weight 270 lbs.

Total -- 165Total -- 165LDL -- 92LDL -- 92HDL -- 64HDL -- 64Trig – 47Trig – 47

Glucose – 84Glucose – 84(Weight 190 lbs)(Weight 190 lbs)

October 8, 2008October 8, 2008

Total -- 230Total -- 230LDL -- 155LDL -- 155HDL -- 38HDL -- 38Trig – 185Trig – 185

Glucose – 124Glucose – 124(Weight 270 lbs)(Weight 270 lbs)

June 11, 2008June 11, 2008

80 lb80 lb

wt losswt loss

Medication TreatmentMedication Treatment

Medication Treatment - StatinsMedication Treatment - Statins Statin drugs should be the cornerstone of Statin drugs should be the cornerstone of

medication treatment for virtually all medication treatment for virtually all patients with elevated cholesterol.patients with elevated cholesterol.

Statins are the only class of drugs to Statins are the only class of drugs to demonstrate clear improvement in overall demonstrate clear improvement in overall mortality in primary and secondary mortality in primary and secondary prevention of coronary heart disease.prevention of coronary heart disease.

Medication Treatment - StatinsMedication Treatment - Statins

The clear benefits of statins have been The clear benefits of statins have been demonstrated repeatedly in multiple well-demonstrated repeatedly in multiple well-controlled randomized clinical trials.controlled randomized clinical trials.

There are more quality studies showing There are more quality studies showing safety and clear benefits of statin drugs, safety and clear benefits of statin drugs, than with all other classes of cholesterol than with all other classes of cholesterol lowering drugs combined.lowering drugs combined.

Medication Treatment - StatinsMedication Treatment - Statins

– LDL: The “bad” cholesterolLDL: The “bad” cholesterol– HDL: The “good” cholesterolHDL: The “good” cholesterol– Triglycerides: Fat particles in blood Triglycerides: Fat particles in blood

This is what matters most

» Decrease LDL by 20-60%!Decrease LDL by 20-60%!» Minimal increase in HDL (up to 10%)Minimal increase in HDL (up to 10%)» Modest improvement in triglycerides (15-35%)Modest improvement in triglycerides (15-35%)

Statins:Statins:

StatinsStatins– LovastatinLovastatin (generic for Mevacor) -1987 (generic for Mevacor) -1987

$4/month at Target/ Walmart$4/month at Target/ Walmart

– Lescol XLLescol XL (fluvastatin) no generic available - 1994 (fluvastatin) no generic available - 1994

– Pravastatin Pravastatin (generic for Pravacol) -1991(generic for Pravacol) -1991 $$4/month at Target/ Walmart4/month at Target/ Walmart

– SimvastatinSimvastatin (generic for Zocor) - 1992 (generic for Zocor) - 1992

– LipitorLipitor (atorvastatin) -no generic available - 1997 (atorvastatin) -no generic available - 1997

– CrestorCrestor (rosuvastatin) -no generic available - 2003 (rosuvastatin) -no generic available - 2003Most Most potentpotent

Least Least potentpotent

Other MedicationsOther Medications Gut absorption inhibitorsGut absorption inhibitors

– Ezetimibe (Zetia)Ezetimibe (Zetia)

» Moderate LDL reduction (Moderate LDL reduction (≈ 20%)≈ 20%)» No effect on HDL No effect on HDL » No effect on triglyceridesNo effect on triglycerides

– Vytorin (simvastatin plus ezetimibe)Vytorin (simvastatin plus ezetimibe)

Recent study (ENHANCE) showed no clinical benefit toRecent study (ENHANCE) showed no clinical benefit to ezetimibe plus simvastatin, compared to simvastatin aloneezetimibe plus simvastatin, compared to simvastatin alone

Other MedicationsOther Medications

FibratesFibrates – Gemfibrozil (Lopid)Gemfibrozil (Lopid)– Fenofibrate (Tricor, Antara, Lofibra)Fenofibrate (Tricor, Antara, Lofibra)

» Minimal LDL reduction (Minimal LDL reduction (≈ 10%)≈ 10%)» Modest HDL improvement (up to 25%)Modest HDL improvement (up to 25%)» Best for triglyceride reduction (up to 50%)Best for triglyceride reduction (up to 50%)

Other MedicationsOther Medications

NiacinNiacin – Niaspan, Slo-Niacin Niaspan, Slo-Niacin

» Minimal LDL reduction (Minimal LDL reduction (≈ 15%)≈ 15%)» Modest HDL improvement (15-35%)Modest HDL improvement (15-35%)» Modest triglyceride reduction (25- 30%)Modest triglyceride reduction (25- 30%)

– Limited by tolerability (flushing)Limited by tolerability (flushing)

Other MedicationsOther Medications Fish Oils (Omega 3’s)Fish Oils (Omega 3’s)

– Lovasa (previously Omacor)Lovasa (previously Omacor)– Many OTC versions availableMany OTC versions available

» No LDL reductionNo LDL reduction» Minimal HDL improvement (3%)Minimal HDL improvement (3%)» Moderate triglyceride reduction (up to 50%)Moderate triglyceride reduction (up to 50%)

– Limited by GI side effects (oily stool)Limited by GI side effects (oily stool)

Herbals and Alternative TreatmentsHerbals and Alternative Treatments Red Yeast RiceRed Yeast Rice

– Used in Chinese medicine to Used in Chinese medicine to remove “blood blockages” dating remove “blood blockages” dating back to Tang Dynasty (800AD)back to Tang Dynasty (800AD)

– May lower LDL ≈ 20% May lower LDL ≈ 20%

– Active ingredient is lovastatin.Active ingredient is lovastatin.

– Banned for sale in US by FDA, but may find it in Banned for sale in US by FDA, but may find it in Asian markets, internet, etc.Asian markets, internet, etc.

– Problems with purity, contaminants, lack of Problems with purity, contaminants, lack of standardization.standardization.

Herbals and Alternative TreatmentsHerbals and Alternative Treatments

Plant Sterols and StanolsPlant Sterols and Stanols

– Nature Made “Cholest-off”Nature Made “Cholest-off”– Many other products such as Promise-Active Many other products such as Promise-Active

spread, Promise-Active supershots, Benecol, spread, Promise-Active supershots, Benecol, Minute Maid Heart-Wise, Rice Dream Heart-Minute Maid Heart-Wise, Rice Dream Heart-Wise beveragesWise beverages

» May reduce LDL slightly by inhibiting cholesterol May reduce LDL slightly by inhibiting cholesterol absorptionabsorption

» There are NO clinical studies showing any benefitThere are NO clinical studies showing any benefit

» A study in mice showed harmA study in mice showed harm

Herbals and Alternative TreatmentsHerbals and Alternative Treatments

Soy (isoflavones)Soy (isoflavones)

– Has estrogen-like properties.Has estrogen-like properties.

– Initial studies suggested benefit, but a more recent Initial studies suggested benefit, but a more recent systematic review showed only minimal benefit (3% systematic review showed only minimal benefit (3% LDL reduction) from large quantities of soy.LDL reduction) from large quantities of soy.

– Feel free to substitute soy products for animal-derived Feel free to substitute soy products for animal-derived products because they are low in saturated fat, high products because they are low in saturated fat, high unsaturated fat, high fiber.unsaturated fat, high fiber.

– But, don’t take soy with the intention that it will lower But, don’t take soy with the intention that it will lower your cholesterol.your cholesterol.

Herbals and Alternative TreatmentsHerbals and Alternative Treatments

Green Tea ExtractGreen Tea Extract– A small randomized controlled trial showed a A small randomized controlled trial showed a

statistically significant benefit, statistically significant benefit, ≈≈10% LDL reduction10% LDL reduction

GarlicGarlic– Recent large well-controlled trial showed no Recent large well-controlled trial showed no

benefit benefit FiberFiber (psyllium, oats, etc.) (psyllium, oats, etc.)

– Recent randomized controlled study showed Recent randomized controlled study showed statistically significant LDL reduction (≈10%) statistically significant LDL reduction (≈10%)

– AHA recommends high fiber diet as “optional AHA recommends high fiber diet as “optional dietary strategy to lower cholesterol”dietary strategy to lower cholesterol”

MKMGMKMG

Michael S.Wein, MDMichael S.Wein, MDKatonah OfficeKatonah Office

(914) 232-3135(914) 232-3135

MOUNT KISCO MEDICAL GROUPMOUNT KISCO MEDICAL GROUP