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Health Matters

By Virginia Lester,
RN, MSN, ARNP

I have decided to write on an issue that I feel I face almost every day. In short, it is the topic of elevation of one or more of the lipid profile (total cholesterol, triglycerides, high density lipoproteins, low density lipoproteins and very low density lipoproteins). We are familiar with elevated blood pressure known as the “silent killer” because often by the time it is identified much damage has already been done to the circulatory system. Today, we are aware of a silent insidious condition known as elevated or abnormal lipids which occurs earlier with the end result of narrowed arteries and high blood pressure.

Coronary heart disease (CHD) continues to reign as the number one killer in the U.S. Lipid management is a crucial preventative strategy for those identified to be at risk. Presently, the lowering of the low density lipoprotein cholesterol (LDL-C) appears to offer powerful protection against heart attacks, strokes and early death. The important thing is to identify those at risk early and get them started on preventive changes. This includes lifestyle changes: dietary, exercise, and smoking cessation and if appropriate, medication. The initial drug therapy of choice is a statin. A long series of well designed and controlled clinical trials has consistently demonstrated that statin therapy can reduce the incidence of heart attack, angina, strokes and early death by up to one third in patients most at risk without compromising safety.

Response to diet will vary. In general, a low fat diet will decrease the LDL-C by seven – 10 percent. Some patients who are highly motivated can reduce their fat intake to less than 10 grams per day and decrease LDL-C up to 30 percent, more likely with a plant-based diet. The main problem with this method is that a very low fat diet is difficult to maintain. A target goal and time limit should be set for the diet trial period commonly three to six months.

Who should be taking statin medications? The National Cholesterol Education Program Adult Treatment Panel III (NCEP) has delineated four levels of risk based on a calculation that includes family history, age, sex, weight/height/BMI, waist circumference, the lipid profile, blood pressure and fasting glucose level. This formula helps identify patients who may not have overt CHD but who have the CHD risk equivalents that make them candidates for preventive therapy.

The NCEP has suggested a goal for an optimal LDL-C of less than 100mg/dL for everyone, regardless of risk. They do not recommend drug therapy to reach this goal for everyone. Instead, the recommendations are geared to the individual patient’s risk for CHD. The LDL-C for the highest risk is a goal of less than 70mg/dL while the level for the lowest risk should be below 160mg/dL. The emerging data from clinical trials show a clear trend toward the concept that lower is better regardless of the risk factor calculation and patients at risk for CHD at any level will benefit from lipid lowering drugs. Patients who have been diagnosed with acute or stable CHD, diabetes, vascular disease or multiple risk factors should be on aggressive statin therapy even if their LDL-C is normal.

People who should not be taking statin medications are those who have previously developed significant adverse events on a statin; those whose target goals are reachable through diet and exercise alone; women who are or may become pregnant or are nursing mothers and people with significant underlying liver disease.

Very often patients are reluctant to begin taking a statin because of what they have heard on TV or read on the internet regarding side effects. Fears based on perceived risks of statins are exaggerated. Liver damage has never been demonstrated and rhabdomyolysis (severe muscle wasting), while a true hazard, is extremely rare even at the highest dosages. Short term side effects that decrease over time is bloating and stomach upset.

Mild muscle aching is common but must be reported in the event that it could be a symptom of a more serious reaction. Your clinician is obligated to evaluate the reaction to rule out the severe form of muscle wasting. The F.D.A. regulations require that all side effects (even if only one) on all prescription medications be identified in the medical and patient information literature. A side bar is noted in that this is not true about non-prescription medications and herbal remedies. Since they are considered a food supplement, side effects are not required to be publicized.

In summary, side effects are always a possibility, however remote, and emphasizing the importance of professional monitoring with laboratory testing and judicious use of medication for each patient is the key. The risk to benefit numbers must be weighed by the patient and clinician. The side effect risks with statin therapy is 0.5 to 1.2 ; while the benefits are 30 – 40 percent in favor of preventing a serious CHD event. Do the math.

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