Cholesterol Solutions Today:The Good & The Bad

Filed under: Diet, Prevention, NutritionTwo grams per day of sterols and/or stanols can promote heart health, reducing cholesterol levels by around ten percent in as little as two weeks. They are most beneficial for people whose cholesterol levels are already elevated. According to one study, sterols and stanols together are more effective than a double-dose of cholesterol-lowering medications! Not bad for a bunch of little-known plant compounds, huh?The catch with sterols and stanols is working out how to get enough. Two grams daily. Doesn’t sound like much. And, true, sterols and stanols are found in a great many foods - avocados, corn oil, apples, oranges, beans and peanut butter, to name a few. But they occur in minute amounts, making it hard to get as much as two grams daily. Example? The olive oil shown in the picture I’ve used at right only contains about 0.03 grams of sterols per tablespoon.To the rescue (for a price!) come food manufacturers. Eager to cash in on a growing demand for the healthful compounds, these companies are releasing sterol- and stanol-fortified foods onto the market at a steady pace. A couple of examples: CocoaVia chocolate covered almonds, Rice Dream Heartwise vanilla-flavored rice milk, and Minute Maid Heartwise orange juice. With heart disease the number one killer in the US, demand for such products will likely continue to grow. Want to know more? Click here to view a handy dandy chart of easy-to-find supermarket foods containing sterols/stanols.Read | Permalink | Email this | Linking Blogs | Comments (Source: The Cardio Blog)

Bill BestermannWhenever a commercial runs on television and the topic is a statin drug, there is a long rendition of potential side effects.  There are warnings that you should report muscle pain or weakness and that you should have tests to check your liver.  Certainly, reasonable caution is prudent with any medication but one of the main reasons you see a doctor is to have a knowledgeable, wise person help you consider the risks and benefits of a potential treatment.  When it comes to risks and benefits, there is no happier story in all of medicine than the statin drugs in lowering cholesterol.These medications are very powerful.  In South Carolina, where I practiced for 30 years, roughly half of the population dies of vascular events.  In the early part of my career I admitted a very large number of patients to the hospital with heart attacks and strokes.  Far too many of them died.  We just did not have very much that worked very well.  When I entered medical school, I was performing calculations with a slide rule.  It is hard to realize just how much the world has changed and the medical world has changed technically as rapidly as any professional field.  The statin drugs are one of the most amazing technical developments.   The statin drugs do have very real side effects.  Here is the big picture.  I have admitted hundreds of patients to the hospital with problems caused by arterial disease.  Many of them died.  I have admitted one patient to the hospital with a cholesterol therapy complication-and he walked out of the hospital.  The television commercials on statin therapy warn of liver problems.  If you compare a million patient-years of statin use with a million patient-years of no statin use-there is no difference in the number of serious liver problems.  I have never admitted anyone with a statin-related liver problem.  There is an issue of muscle pain or weakness.  The incidence of muscle pain or cramps may be from 1%-5%.  But the problem is that so many patients who are at risk have aches and pains anyway.   The pain that goes with statin muscle injury is like the flu—it is all over the body—it is diffuse.  If you think you are weak but you can get out of a chair without using your arms to push up—you probably do not have a significant statin myopathy.   Significant muscle injury can be detected by measuring a CPK lab test.  Muscle injury occurs more frequently when statin drugs are used in combination with other medications that cause the level of the statin drug to increase.  Many times we can get around the muscular complaints by changing the drug or the dose.  Only one in 10,000 patients treated with a statin develops the serious muscle injury called rhabdomyolysis.These medications have a very powerful effect in preventing cardiovascular events.  Statin therapy alone reduces coronary mortality by 42% and combination therapy (statin plus niacin) aimed at abnormal lipids may lower vascular events by as much as 90%.  These effects are almost immediate, extremely potent, and very impressive.  If a single dose of a statin drug is given to a laboratory animal prior to the creation of an experimental infarction, thesize of that infarction is reduced by half.  That is important news because it is the size of the infarction that determines the likelihood of most of the adverse outcomes of the heart attack including congestive heart failure-the number one cause of hospitalization for Medicare patients.Bench science with rats sometimes does not extend to humans, but data from the National Registry of Myocardial Infarction suggests that we can extend this concept to patients.  There were 300,823 patients in the registry reporting to the emergency room with an acute heart attack.  Myocardial infarction victims with new or continued statin treatment during the first 24 hours experienced a mortality of 5% and those with no statin treatment experienced  a mortality of 15%.  Statin-treated patients had lower risk of cardiogenic shock, arrhythmias, cardiac arrest and rupture—all typically related to the amount of heart muscle killed by the artery blockage.Finally, treatment with statin drugs can lead to achieving that most elusive goal in the treatment of vascular disease.  You can reverse cholesterol buildup in your arteries.  Dr Steven Nissen of the Cleveland Clinic has proved this in the Asteroid trial.  Using an intravascular ultrasound catheter (IVUS), Dr Nissen was able to show that lowering LDL cholesterol to 62 with high-dose Lipitor (atorvastatin) significantly reduced the size of the cholesterol deposit obstructing a heart artery.  When you examine the IVUS catheter trials that have looked at how the amount of plaque changes depending on the LDL level, it looks like the break point is in the mid-70s.  When your LDL is over 75 you are putting cholesterol down in the artery.  When it is less than 75, you are pulling cholesterol out and not just in that artery, but in all of the arteries in the body.The statin medications to lower LDL cholesterol are a great addition to the tools that are available to reduce the toll of arterial vascular disease.  It is important to approach them with a positive attitude and if you think you have a side effect you need to discuss it with your doctor.  Is it really related to the statin?  Is it severe enough to warrant stopping the drug.  Can it be reduced or eliminated by changing the drug, reducing the dose, or changing other medications in the medication program.?  It is important to find a way to continue these medications if this goal can be accomplished safely—and usually it can be!William Bestermann is Medical Director of the Vascular Medicine Center of the Holston Medical Group in Kingsport, TN. He is also President of the Cardiovascular Center of Excellence program under the auspices of the Consortium for Southeast Hypertension Control.  Click here to read his other articles on TDWI . You can reach Dr. Bestermann at whb@hmgkpt.com. (Source: The Doctor Weighs In)

Filed under: DietAvocados are a pretty trendy vegetable (or is it a fruit?) these days. Not only that, but it’s really good for you. While avocados are fairly high in fat for a produce item (there’s about 15% of your recommended daily intake in 1,) it’s a trade-off because they have lots of vitamins, including Vitamins B, E and K, and they also have important nutrients like potassium and folate.For the heart conscious, avocados can help regulate your cholesterol and blood pressure, according to this article. Furthermore, the folate in avocados can significantly reduce the risk of cardiovascular disease. So if you like avocados, eat up! I personally can’t stand them on their own, so I’ll be enjoying some home-made guacamole or trying to hide some in a salad or sandwich.Read | Permalink | Email this | Linking Blogs | Comments (Source: The Cardio Blog)

by Bill Besterman The underpinning for much of the death and disability from arterial vascular disease in this country is the metabolic syndrome. One of the real authorities on the metabolic syndrome is a Dr. Ralph DeFronzo.  I particularly like his description of of this collection of disorders as a “complex metabolic web.”  The patients who have this diagnosis are burdened with multiple chronic conditions: hypertension, high bad or LDL cholesterol, high triglycerides, low HDL or good cholesterol, and high blood sugar ultimately resulting in type 2 diabetes. These patients routinely have vascular systems where the vessels are inflamed and the blood more likely to clot. Early in the condition the arteries are thicker and less distensible than in people without the syndrome; progression of the arterial disease is the norm. Many of affected individuals also have gout. More recently, the metabolic syndrome has been called the cardiometabolic syndrome because this name underscores the impact of these conditions on the heart and the rest of the vascular system. Metabolic syndrome patients have an increased risk of coronary artery disease, cardiac enlargement and congestive heart failure.  Type 2 diabetes is the late stage of the syndrome Dr. DeFronzo highlights a very important clinical reality in describing the cardiometabolic syndrome as a complex metabolic web. "Job one" of the clinicians who treat these patients is to unravel that complex web using every medical and lifestyle tool in the medical toolbox. Only 7% of these patients have all of their risk factors (hypertension, blood sugar, and cholesterol) simultaneously controlled to the most conservative goals. For each risk factor that is controlled, using the proper interventions, the risk of all adverse outcomes is reduced by roughly 50%. So, the task of the clinician is not just to control hypertension or diabetes, but rather to control all risk factors to goal at the same time.That is where the focus, skill and training of your provider come into play. The particular medical choices that are made are critical for success. For three decades now I have heard physicians blame patients for not being “compliant:” “Mrs. Brown is diabetic and she does not listen to a thing I tell her. She just stuffs herself with anything she wants and she continues to gain weight.” Here is the reality. Every medication commonly used for the treatment of type 2 diabetes causes weight gain with the exception of metformin (Glucophage) and the Byetta-type medications. The new drug Januvia is weight neutral. Most patients do not have their sugar controlled to goal using a single medication. Most patients require multiple drugs and even then progressive loss of glucose control is the norm. Weight gain not only makes control of the sugar more difficult—the metabolic syndrome is itself worsened by increased abdominal weight—weight gain also makes controlling pressure, cholesterol, triglycerides and gout more difficult. The patient that receives a prescription for two shots of NPH insulin a day will gain 10 pounds in a year. The patient that uses glyburide plus a single shot of NPH gains 9 pounds. The regimen combining  glyburide, metformin and a single shot of NPH, produces a similar weight gain. Metformin added to a single injection of NPH at bedtime produces no weight gain, the best control of the blood sugar and the least number of hypoglycemic attacks. The doctor with the prescription pad is producing this result—not the patient. These are impressive weight changes and they make a big difference over time. I have treated 450 type 2 diabetics for nearly 10 years with a regimen based on metformin and a long-acting insulin injection with durable control in most patients.The treatment of high blood pressure hides the same kind of traps. Until very recently beta blockers like propranolol (Inderal), metoprolol (Toprol) and atenolol (Tenormin) were recommended as first line therapies for the treatment of hypertension.  Many patients continue to be on these medications for the one purpose of treating high blood pressure. These medications have important metabolic effects:Propranolol increases triglycerides by 25%, decreases HDL by 10%, increases total cholesterol by 9% and increases insulin resistance by 33%Metoprolol increases triglycerides by 30%, decreases HDL by 7%, decreases total cholesterol by 1%, and increases insulin resistance by 21%Tricor (fenofibrate) is prescribed to treat the lipid or cholesterol abnormalities that go with the metabolic syndrome decreases triblycerides by 29%, increases HDL by 11%, and decreases total cholesterol by 18%.  When we prescribe propranolol and fenofibrate simultaneously, we have simply cancelled the lipid effect of two drugs. The prescription of propranolol makes it 28% more likely that the patient will develop diabetes. Choosing an ACE inhibitor makes it 33% less likely that a patient will develop diabetes. These are critical metabolic issues. There is a newer beta blocker carvedilol, with dramatically improved metabolic effects relative to the older drugs. The point of all this is that treatment of these patients is very complex if it is done properly. 95% of type 2 diabetes care is provided by primary care doctors who are under tremendous pressure to see patients at the rate of 5-6 per hour. They are required to be experts in the whole massive knowledge base of medical practice We need focused clinics of the type described by the Institute of Medicine to treat metabolic syndrome patients. The providers in these clinics will need to be very expert in the coordinated, integrated management of metabolic syndrome patients and the resulting complications. Until that happens, we will continue to produce the same poor levels of risk factor control and pay a terrible price in lives, disability, and treasure. (Source: The Doctor Weighs In)