Understanding and Controlling Cholesterol

1. Understanding and Controlling Cholesterol MKMG MOUNT KISCO MEDICAL GROUP Michael S.Wein, MD Katonah Office (914) 232-3135

2. Disclaimers, disclosures, conflicts of interest, etc… Absolutely none

3. 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.

4. 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

5. 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

6. 4x risk ½x risk Why it’s so important to control your cholesterol • There is a continuous, graded relationship between total cholesterol and coronary heart risk.

7. 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.

8. Understanding the numbers….

9. This is what matters most 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

10. 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.

11. 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

12. 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

13. Patient A Patient B Total -- 250 LDL -- 180 HDL -- 26 Trig -- 220 Total -- 250 LDL -- 125 HDL -- 96 Trig -- 145 Understanding the numbers… Total cholesterol = LDL + HDL + 1/5 triglycerides Take home point: “Total cholesterol” can be very misleading; pay attention to what makes up the total

14. 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?

15. Diet and Lifestyle

16. 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

17. 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 Dietary changes

18. 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.

19. June 11, 2008 October 8, 2008 Total -- 165 LDL -- 92 HDL -- 64 Trig – 47 Glucose – 84 (Weight 190 lbs) Total -- 230 LDL -- 155 HDL -- 38 Trig – 185 Glucose – 124 (Weight 270 lbs) 80 lb wt loss Case Study 19-year-old college student saw me for a physical. Height 5’10”; Weight 270 lbs.

20. Medication Treatment

21. 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.

22. 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.

23. Statins: This is what matters most • Decrease LDL by 20-60%! • Minimal increase in HDL (up to 10%) • Modest improvement in triglycerides (15-35%) Medication Treatment - Statins • LDL: The “bad” cholesterol • HDL: The “good” cholesterol • Triglycerides: Fat particles in blood

24. Statins Least potent • Lovastatin (generic for Mevacor) -1987 • $4/month at Target/ Walmart • 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

25. 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

26. 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%)

27. Other Medications • Niacin • Niaspan, Slo-Niacin • Minimal LDL reduction (≈ 15%) • Modest HDL improvement (15-35%) • Modest triglyceride reduction (25- 30%) • Limited by tolerability (flushing)

28. 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)

29. 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.

30. 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

31. 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.

32. 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”

33. MOUNT KISCO MEDICAL GROUP MKMG Michael S.Wein, MD Katonah Office (914) 232-3135