Statin Guidelines – The Fight Continues

It’s startling how much debate and disagreement exists about the guidelines for statin use.

Back in November 2013, new guidelines were published by the American Heart Association and the American College of Cardiology. The 2013 guidelines represented a significant shift in cholesterol management: essentially moving away from targeting/treating to a specific cholesterol level and instead encouraging treatment of all individuals with a 10-year risk of heart disease of 7.5% or higher (for specifics, see my post, The NEW guidelines for cholesterol-lowering statin meds).

There then ensued heated arguments over the published Risk Calculator that yields that all-important 10-year level of heart disease risk. Indeed, clicking the AHA’s Heart Attack Risk Assessment page right now yields this frustrating error:

“We’re sorry, but this tool is currently unavailable. The Heart Attack Risk Calculator is being updated and will be available soon. Please check back!”

Luckily, the AHA’s Prevention Guidelines page with a link to the original calculator still exists, so you can still calculate your 10-year risk. (Note: if these links fail, try my RESOURCES page: I’ll try to keep the risk calculator links up-to-date there.)

Assuming one believes at least directionally in the AHA’s risk calculator (and I do), it’s important for those who can use the calculator* and assess your personal level of heart disease risk over the next 10 years. (* You cannot use the calculator if you have heart disease or take statins already. Read more about calculators here.)

Until yesterday, it was clear what to do with your resulting risk: if someone between 40-75** gets a 10-year risk of heart disease of 7.5% or more, statin therapy should be considered and discussed with a doctor. (** See full 11/2013 recommendations below.)

But yesterday, things got a little tricky for anyone whose risk is between 7.5% and 10%.

Because yesterday, the U.S. Preventive Services Task Force issued new guidance for the use of statins which is not exactly the same as the AHA 2013 guidelines. (The USPSTF guidelines were published in the Journal of the American Medical Association; read/download a PDF here).

  • On the plus side, the new USPSTF guidelines support the November 2013 AHA decision in that the new guidelines are also based on the 10-year risk calculator. So the USPSTF added weight to the argument for using 10-year risk calculator, and not treating by managing to a particular LDL cholesterol level.
  • On the tricky side, the new USPSTF guidelines increased the risk of heart disease cutoff from 7.5% to 10%.

So now it’s not entirely clear what someone with a risk rate of 7.5%-10% should do. And whether insurance will cover statins for those individuals.

That’s because, as Ariana Eunjung Cha of The Washington Post astutely points out in her excellent article, New Statin Guidelines: Everyone 40 and older should be considered for the drug therapy, both Medicare and the Affordable Care Act use USPSTF recommendations to guide drug coverage plans. So that MAY call into question whether insurance companies will cover statin drugs for those in the 7.5% to 10% risk group.

In the end, what’s important is this: calculate your 10-year risk of heart disease. Use the calculator, and:

  • If you’re below 7.5%, make sure to keep pursuing a lo-co lifestyle with frequent exercise and a healthy, low-fat, low-sugar, plant-based diet.
  • If your risk is over 10%, get thee to a doctor and discuss statins.
  • If your risk is between 7.5% and 10%, talk to your doctor or cardiologist about what next steps are right for you.

It all starts with your risk: calculate it!  It’s so easy – all you need is your latest cholesterol results and systolic blood pressure (the first number).  Then review your personal results and make a plan with your doctor.

Supplement:
** November 2013 AHA recommendation: if you are in one of the following four groups, you have elevated heart disease risk and should take statins:

  1. those who already have cardiovascular disease
  2. anyone with LDL (bad) cholesterol of 190 mg/dL or higher
  3. anyone between 40 and 75 years of age who has Type 2 diabetes
  4. people between 40 and 75 who have an estimated 10-year risk of cardiovascular disease of 7.5 percent or higher.

The USPSTF November 2016 recommendation:
“The USPSTF recommends that adults without a history of cardiovascular disease (CVD) (ie, symptomatic coronary artery disease or ischemic stroke) use a low- to moderate-dose statin for the prevention of CVD events and mortality when all of the following criteria are met: 1) they are aged 40 to 75 years; 2) they have 1 or more CVD risk factors (ie, dyslipidemia, diabetes, hypertension, or smoking); and 3) they have a calculated 10-year risk of a cardiovascular event of 10% or greater.”

Share

How Much Exercise For Boosting Heart Health?

Exercise is one of the key methods for lowering cholesterol – and blood pressure, my new concern — without medications. So to reduce my blood pressure and to continue to keep my cholesterol in check without any meds, I’ve been wondering just how much, how hard, and how often I need to exercise.

In researching, I found this nifty chart from the American Heart Association. It’s a little busy, but the key is the bottom-most graphic, which is for lowering cholesterol and blood pressure (how handy that they are together goal-wise!)

Apparently, to lower cholesterol and blood pressure, one needs to exercise for an average of 40 minutes at a ‘moderate-to-vigorous-intensity aerobic activity’ 3-4 days each week.

AHA Exercise Guidelines

Which sounds like kind of a lot, people.

I mean, I can jog for 20 minutes before my knees hurt – but certainly not 40 minutes (I was awed when my 21 year old son ran the Chicago marathon in 3 hours and 49 minutes. I still can’t believe he did that / that anyone can run for that long!).  So, um, 40 minutes of ‘moderate-to-vigorous’ exercise 3-4 times a week sounds like a LOT to me.

So obviously, the key question is – what is ‘moderate-to-vigorous-intensity’ aerobic activity?

To me, moderate-vigorous seems like it’d be exercise that gets my heart rate to hit at about 70-85% of my Max Heart Rate (for me, that’s 140-154 or so). If you want to know more about setting a personal heart rate goal, read How To Set A Simple Heart Rate Goal. But is that moderate or is that vigorous?

Luckily, the American Heart Association had a post that answered that exact question: Moderate to Vigorous – What is your level of intensity?  The AHA defines moderate and vigorous exercise as follows (link to the article for more detailed, pretty interesting info):

Examples of Moderate Intensity:

  • Walking briskly (3 miles per hour or faster, but not race-walking)
  • Water aerobics
  • Bicycling slower than 10 miles per hour
  • Tennis (doubles)
  • Ballroom dancing
  • General gardening

Examples of Vigorous Intensity:

  • Race walking, jogging, or running
  • Swimming laps
  • Tennis (singles)
  • Aerobic dancing
  • Bicycling 10 miles per hour or faster
  • Jumping rope
  • Heavy gardening (continuous digging or hoeing)
  • Hiking uphill or with a heavy backpack

Whew. I can walk quickly for 40 minutes to count as heart-healthy exercise. Yay – that’s one I can actually do!  But walking is kind of boring to me – and 40 minutes still feels like a lot of time.

So I need another option. One that’s vigorous but doesn’t eat into my day. Which is why I’m intrigued by High-Intensity Interval Training. In fact, this explanation of HIIT from Karen Reed of Positive Health Wellness was music to my ears, “Thanks to the non-stop, high-intensity pace of the workout, you can fit in both aerobic (cardio) and anaerobic (resistance training) exercise in just 15 to 25 minutes.” For more details, read her article, “All The Benefits of High Intensity Interval Training Workouts.”

I’d rather ramp up my exercise plan than go on blood pressure or cholesterol meds, so I’m looking at trying out High-Intensity Interval Training and/or scheduling more – or longer – aerobic exercise into my week. How about you?

 

Share

Non-Sweetened Metamucil with Grapefruit and Orange Juice

With my cholesterol, triglycerides and blood pressure higher last month, I needed to try to salvage things before my doctor(s) advise statins and/or blood pressure medication. Step one: a lo-co lifestyle exercise and diet review (and correction):

  • Exercise. I’d let my exercise habit lapse in the past six months, so have recently re-started exercising daily. Of course today I pulled my hamstring. Sigh. But I am determined to at least walk daily, because ‘Study Proves Exercise Staves Off Bad Cholesterol.’
  • Diet – General. While I don’t eat a lot of red meat, I do eat a lot of carbs (pasta and bread) and sugar (M&Ms and wine). So I’m cutting down on pasta, pizza and sticking with 1 glass of rose per night. And M&Ms, well…not sure how they got back into my diet but it ends now.
  • Diet – Supplements. As with exercise, I had stopped my daily dose of Metamucil. Which is lame, because Metamucil both lowers cholesterol and helps with diverticulosis, which I also have. So I tossed my very expired Metamucil and bought a new, huge jar of Orange Smooth Metamucil, with sugar.

Metamucil_SugarThen I got to thinking about that Metamucil. I chose Orange Smooth Metamucil (with sugar) because I both despise aspartame and believe it to be unhealthy. As all the sugar-free Metamucil products have aspartame, that left me with the Metamucil with sugar. But with sugar-sensitive high triglycerides and a desire for a nightly glass of wine, it seemed sugared Metamucil might not be a great choice.

Metamucil_OriginalSmoothSo I dug a bit more and found ONE Metamucil product with neither sugar nor aspartame. Called Metamucil Original Smooth, it was just what I was looking for. Oh, except for the taste. While I did not despise the ‘wheat-y’ taste as much as others on the internet seem to, it was certainly not a flavor I wanted to wake up to every morning.

So I started thinking about how Going Lo-Co reader Eileen makes a cholesterol-loweirng grapefruit juice / Metamucil smoothie: info here.) Smoothies are too much work for me, so I looked around on the web and found many who said they mixed the Original Smooth with juice. Which is what my Mom does too – she mixes Metamucil with diluted orange juice. But OJ is just a lot of sugar with no cholesterol-lowering benefit so that did not appeal. Then it hit me: what if I combined grapefruit and orange juice?**

This morning, I stirred up an inaugural glass of Going Lo-Co Metamucil Elixir. To make it, I combined 1 teaspoon of Metamucil Original Smooth with 4 ounces of grapefruit juice, splashed in some (about 1 oz) orange juice to cut the tartness of the grapefruit juice, then topped it off with about 2 oz of water.  After a vigorous stir, I guzzled it.

I am pleased to say that I really liked it. Well, as much as one likes these things.

The taste is decent AND unlike sugared Metamucil, my version delivers potassium AND the blood pressure, cholesterol, and triglyceride lowering properties of grapefruit juice (see Grapefruit Pros and Cons for more info.)

Then I estimated the nutritional value for my Going Lo-Co Metamucil Elixir. My concoction does have more calories and sugar than sugared Metamucil, but I’m willing to accept those extra 30 calories and 4 grams of sugar for the better taste AND potassium AND the cholesterol-lowering benefits of grapefruit juice. Here’s how they compare:

Metamucil Grapefruit OJ
If you don’t take ANY medications, give my Going Lo-Co Metamucil mix a whirl. If you do take medication – any medication – read message below: and do NOT try this unless you’ve consulted with your doctor.

** VERY IMPORTANT:  do NOT try this ‘recipe’ — in fact, do NOT drink any grapefruit juice — if you are on statins or other medications. Specifically, do NOT eat grapefruit or drink grapefruit juice if you take Lipitor or any other statin medication to lower cholesterol without speaking first to your doctor.  Same grapefruit warning exists if you take other types of medications that can also interact with grapefruit juice, including drugs for blood pressure, heart rhythm, depression, anxiety, HIV, immunosuppression, allergies, impotence, and seizures.  It is dangerous to start eating grapefruit (or drinking grapefruit juice) if you take any of these medications – unless you speak to your doctor first.

Share

New Study Suggests Statins For Those at Low Risk

A new study published in March 2016 by McGill University’s George Thanassoulis, MD in the Circulation journal of the American Heart Association suggests that many identified as ‘Low Risk’ by the latest cholesterol treatment guidelines should be taking cholesterol-lowering statins.

The current guidelines for treating cholesterol, published with much fanfare and controversy in November 2013, moved away from targeting treatment to reach a specific cholesterol level and instead include a ‘calculator’ that measures risk. If a person’s risk is lower than 7.5% chance of heart disease in 10 years, statins are NOT recommended. (Details, including a link to the calculator, found in my post: The NEW Guidelines for Cholesterol-Lowering Statin Meds.)

Personally, I fall into the ‘do not take statins’ pool using this calculator as:  a) I do not already have cardiovascular disease; b) my LDL (bad) cholesterol is less than 190; c) I do not have diabetes; and d) my 10-year risk is lower than 7.5%.

But according to this NEW March 2016 study, “Individualized Statin Benefit for Determining Statin Eligibility in the Primary Prevention of Cardiovascular Disease,” I might be one of the many at ‘low risk’ who should be taking statins!

Yikes.

The new study recommends “an INDIVIDUALIZED statin benefit approach” rather than relying on the calculator; using this approach, thousands who are currently at ‘low risk’ and not treated with statins would instead be treated with statins. According to the study authors, “Statin treatment in this group would be expected to prevent an additional 266,508 cardiovascular events over 10 years.”

Yikes times two.

And it was a large study. The study, “included 2134 participants representing 71.8 million American residents potentially eligible for statins in primary prevention from the National Health and Nutrition Examination Survey for the years 2005 to 2010.”  The study “compared statin eligibilities using 2 separate approaches: a 10-year risk-based approach (≥7.5% 10-year risk) and an individualized benefit approach (ie, based on predicted absolute risk reduction over 10 years [ARR10] ≥2.3% from randomized, controlled trial data).”

The risk-based approach (the ‘new’ 2013 guidelines that doctors are currently using) identified 15.0 million Americans who should take statins, versus 24.6 million Americans who should take statins according to the benefit-based approach. Thus, “the benefit-based approach identified 9.5 million lower-risk (<7.5% 10-year risk) Americans not currently eligible for statin treatment who had the same or greater expected benefit from statins (≥2.3% ARR10) compared with higher-risk individuals.

That’s 10 million Americans who should be taking statins who right now are not.

And I’m probably one of them!  Because the study goes on to say, “This lower-risk/acceptable-benefit group includes younger individuals (mean age, 55.2 versus 62.5 years) with higher low-density lipoprotein cholesterol (140 versus 133 mg/dL). Statin treatment in this group would be expected to prevent an additional 266,508 cardiovascular events over 10 years.

Yikes times three!  As this describes me: I’m under 55 and my LDL is 145.

I guess it’s time to put in a call to my cardiologist and ask what he thinks of this study.  I do not want to go on a statin medication, but I do want to understand his thoughts on both this study and what an “individualized benefit approach” to treating my high cholesterol looks like.

 

Share

Why You Should Ask Your Doctor About HS-CRP

If you have high cholesterol but no other cardiac disease risks, ask your doctor about the High Sensitivity C-Reactive Protein (HS-CRP) test.

The HS-CRP test is an important predictor of heart disease risk. Actually, as explained in Why You Should Ask For Advanced Lipid Testing, if you are concerned about heart disease risk, you might want to ask your doctor about three key tests: HS-CRP, ApoB and LDL Pattern Type. (While they’re separate tests, all are included in one single Advanced Lipid Panel blood test.)

The HS-CRP test in particular predicts heart disease risk by measuring inflammation in the blood vessels. That the HS-CRP blood test is an excellent predictor of heart disease risk has been widely established. A page on the National Institute of Health about HS-CRP states, “Evidence supporting the hypothesis that elevated CRP levels contributes to increased cardiovascular risk is now available from at least six major prospective studies…”

The HS-CRP is particularly relevant for women. WebMD’s Heart Disease and C-Reactive Protein (CRP) Testing article explains that in the large Harvard Women’s Health study (WHS), “results of the CRP test were more accurate than cholesterol levels in predicting heart problems. Twelve different markers of inflammation were studied in healthy, postmenopausal women. After three years, CRP was the strongest predictor of risk. Women in the group with the highest CRP levels were more than four times as likely to have died from coronary disease, or to have suffered a nonfatal heart attack or stroke compared to those with the lowest levels. This group was also more likely to have required a cardiac procedure such as angioplasty (a procedure that opens clogged arteries with the use of a flexible tube) or bypass surgery than women in the group with the lowest levels.”

That said, if you are already taking a statin or being treated for high blood pressure, the HS-CRP test might not be appropriate. According to Dr. Andrew Weil’s What is elevated C-reactive protein? article, “CRP levels don’t appear to help predict the risk of heart disease in patients already being treated for risks such as high blood pressure or high LDL (“bad”) cholesterol. A 2010 analysis of British data on 4,853 patients found that C-reactive protein levels didn’t yield any more information about the risk of heart disease than LDL (“bad”) cholesterol levels or high blood pressure in patients who already were being treated with a cholesterol-lowering statin drug or with medication to lower blood pressure.”  However, it goes on to say that, “Other physicians, including Dr. Weil, think that all adults should have an hs-CRP test whenever their cholesterol is tested.”

A powerful statement.

My cardiologist appears to agree; at my visit on Christmas Eve, he ordered an advanced lipid panel and an HS-CRP test. There was a mixup on the advanced lipid panel prescription (more on that in another post) so I don’t yet have those results, but I was delighted to see that my HS-CRP test came back with even lower risk than last year.

I was surprised at this result, but apparently should not have been. With a bit of research I found that HS-CRP should be measured over time, as there is high variability in this test. According to the Mayo Clinic, “C-reactive protein (CRP) is an acute-phase reactant and has high intraindividual variability. Therefore, a single test for high-sensitivity CRP (hs-CRP) may not reflect an individual patient’s basal hs-CRP level. Repeat measurement may be required to firmly establish an individual’s basal hs-CRP concentration. The lowest of the measurements should be used as the predictive value.”  I saw this in my own results: in December 2014 my HS-CRP level was 0.8 and in December 2015 it was 0.3.

As both of my HS-CRP measurements are below 1.0 mg/L, that puts me at “lower relative cardiovascular risk” according to the goals printed at the bottom of my test results.  Here are the guidelines:

HS-CRP Guidelines

Do you know your heart disease risk as measured by HS-CRP? If you fall into the category of those for whom the HS-CRP test is a good predictor of heart disease risk (meaning, you aren’t already being treated for heart disease or you have an inflammatory disease), ask your doctor about this simple blood test and get more insight into your heart disease risk.

 

Share