When I tell high-risk patients that I think they should take a statin drug and explain why it will help to improve their cholesterol levels, they usually agree. But it is not unusual to get some resistance from patients who aren’t well informed about the potential benefits or side effects of these drugs.
The following are some typical patient reactions:
“No! I don’t want to take any medications. I want to lower my cholesterol naturally, without drugs and their side effects. Won’t drugs fry my liver?”
“Sign me up! I’d rather take a pill than worry about my diet or bother with exercise!”
In both cases, these patients are just cheating themselves.
Patients who reject medications because they think they’re not “natural” are missing out on some of the best tools in aggressive prevention. Statin drugs alone can slash the risk of having a heart attack by more than 30 percent—and by much more than that when taken in combination with other drugs such as niacin, aspirin, and/or certain blood pressure medications.
I am quick to remind patients who make remarks about drugs not being “natural” that there is nothing “natural” about having a sick artery that is burdened with plaque. I also tell them that statin drugs can actually help to restore the artery to its youthful, flexible state— the way that nature intended it to be. And I remind them that a truly “natural” cholesterol level is in the low 100s. At least that is the level found in populations with unprocessed, non-Western diets.
Patients who think that popping a pill renders diet and exercise unnecessary are also making a deadly mistake. Drugs are meant to work together with these lifestyle changes; they are not meant to replace them. Even if a combination of drugs can reduce your risk of having a heart attack by 50 percent, half of all people taking these drugs who were destined for a heart attack will still have one. That’s why making lifestyle changes is so essential to further reduce risk.
Although I am a passionate believer in the power of diet and exercise, given what we know today about the effectiveness of statins and other drugs, it makes no sense at all for at-risk patients not to take them. I made this point recently when I was lecturing at a major medical center about the benefits of good fats, good carbs, and lean protein to a group of physicians. At the end of my talk, after having built a strong case for the role of diet in heart disease prevention, one doctor asked if I would be willing to conduct a study that tested the principles of the South Beach Diet as a sole therapy for patients with coronary artery disease. I was adamant that I would not. Using diet alone to treat heart disease would be ignoring 30 years of lifesaving medical advances.
So does that mean that statins should be universally prescribed in a manner akin to adding fluoride to drinking water to reduce tooth decay? That would be going too far. But statins have generally been underprescribed. Despite numerous excellent studies documenting their effectiveness, millions of people who should be taking these cholesterol-lowering drugs are not. This means that millions of Americans have an unnecessarily high risk of suffering a heart attack, stroke, or sudden death.
Tell your doctor about all the medications and dietary supplements you take regularly, whether they’re prescription or over-the-counter. When taken in combination with other drugs, many otherwise safe medications can interact, causing potentially dangerous side effects. Never stop taking a heart medication without consulting your doctor.
A TALE OF TWO BROTHERS
I’m not suggesting that everyone needs to take a statin to prevent heart disease. In some cases, if a high-risk patient is still young, I allow 3 months to a year to see if diet, exercise, and other lifestyle modifications can make enough difference to avoid medications. Today, thanks to heart scans and advanced blood testing, we can more precisely identify those people who will benefit from taking a statin.
Let me tell you about two brothers, Chuck, 34 years old, and Steven, 36 years old, who came to me because their father had suffered a heart attack at the young age of 49. Both brothers wanted to do everything they could to avoid their father’s fate.
I did heart scans and advanced blood testing on both brothers. Chuck’s scan showed that his arteries already had plaque; with a Calcium Score in the 20s at the young age of 34, it meant his risk of having a future heart attack was high for his age. Furthermore, his advanced blood tests showed that he had high amounts of small, dense LDL, the really bad cholesterol, and low amounts of HDL, the good cholesterol. In comparison, his brother Steven’s arteries were picture-perfect—and so were his blood tests. Unlike Chuck, Steven had probably inherited his mother’s healthier genes.
Chuck left my office with a prescription for Lipitor, a statin drug, to lower his bad LDL cholesterol, as well as one for niacin, which helps reduce the production of small LDL cholesterol and raise HDL. Chuck was also given nutrition counseling and exercise advice. Lucky Steven didn’t need to do anything other than follow a heart-healthy diet and exercise regimen.
Chuck’s case required what in my medical practice we call a “full-court press.” His risk was so high, and there was such a clear genetic component to his problem, that he deserved every antiplaque weapon we had in our arsenal. And, of course, he still needed to be conscientious with regard to diet and exercise.
I have other patients with very bad family histories of premature heart disease who have come to me after a cardiac event. Because of their histories, these patients had made every effort to lead healthy lives. And yet they still developed either angina or heart attacks. As it happened, these events occurred later than they had in other family members, so their exemplary lifestyles did indeed slow their progression of atherosclerosis—but didn’t stop it.
Years ago, in the pre-statin 1980s, I heard a case presentation made by Bill Roberts, MD, a famous cardiac pathologist. He showed the autopsy of a congressman who had tragically died while jogging at age 55. There was extensive plaque buildup in all of the politician’s major coronary arteries. Dr. Roberts remarked that the congressman was a regular long-distance runner and that he had outlived his siblings by a full 10 years due to his vigorous regular exercise routine and his strict diet. But despite his best efforts to fight his genetics with lifestyle alone, it wasn’t good enough. If he had received the benefit of early diagnosis and the best of our current medications to complement his exemplary lifestyle, I am confident he could have survived to a ripe old age.
BUT WILL STATINS REALLY HELP?
Initially, there was some doubt about whether statins would be helpful to anyone other than a small number of patients who were genetically predisposed to very high total cholesterol levels.
Studies conducted in the early 1990s, however, produced some very exciting findings. For example, the landmark 5-year Scandinavian Simvastatin Survival Study (4S) of 4,444 Scandinavian heart patients who were taking Zocor (simvastatin) showed that they had a 34 percent reduction in their risk of dying from heart-related causes and a 37 percent reduction in their chances of undergoing angioplasty or bypass surgery. This was a momentous study because it demonstrated for the first time that a cholesterol-lowering drug had reduced the need for surgery and saved a significant number of lives. Statins were no longer promising—they were proven.
Since then, statins have been studied in dozens of other large and small clinical trials involving tens of thousands of people. One of the newest findings is that when high-dose statins are used to drop LDL cholesterol to very low levels—70 mg/dL or less—there appears to be an even greater reduction in the number of heart attacks, strokes, and sudden deaths.
And there’s more good news about statins. Besides lowering cholesterol, these drugs attack cardiovascular disease on other fronts as well, by calming inflammation, fighting cell-damaging free radicals, and, most importantly, by making vulnerable soft plaque regress and less likely to rupture. As you know from what I’ve said in earlier chapters, plaque rupture is the event that triggers most heart attacks and strokes. The fact that statins do so much more than merely lower cholesterol explains why these drugs are prescribed immediately following a coronary event. In fact, it is now recommended that heart attack patients begin a statin while they are still in the hospital. All told, statins are more effective in managing atherosclerosis and preventing heart attack, stroke, and death than all other classes of medicine.
BUT ARE STATINS SAFE?
Contrary to what you may have heard, today’s statin medications are quite safe. The only serious side effect I have ever seen was an acute breakdown in muscle that can lead to kidney failure and death, which occurred with cerivastatin (Baycol). In 2001, Baycol was taken off the market. While this side effect is reported with other statins, it is exceedingly rare, and if recognized early, it is completely reversible. I personally have never observed this complication with any of the statins I currently prescribe.
In fact, in five major studies involving 30,817 patients who were prescribed statins, only one person had a severe muscle complication, and there were no cases of serious liver disease, another potential side effect. The only problems with statins that I do see fairly commonly are muscle aches and pains and occasionally muscle cramps, particularly in the toes. I have found that switching a patient to a different statin drug or altering the dosage often helps. These harmless aches and pains are not a sign of the serious muscle complication just described. However, do tell your doctor if you are having any muscle pain.
CHOLESTEROL—HOW LOW SHOULD IT GO?
If you have established heart disease or are at high risk, aggressive cholesterol lowering is beneficial no matter what cholesterol levels you start with. There are a number of studies that demonstrate this.
In fact, one of the five statin studies referred to above, the 1998 Air Force/ Texas Atherosclerosis Coronary Prevention Study, was different from prior statin investigations. In this study, the participants started with normal levels of total and LDL (“bad”) cholesterol and no obvious signs of cardiovascular disease. Understandably, many people thought that giving statins to people with normal LDL cholesterol was “overkill.” In truth, it turned out to be lifesaving. Compared to people who were given a sugar pill (placebo), those who took a statin had a 37 percent lower risk of having a heart attack, unstable angina, or sudden cardiac death.
A more recent study, the 5-year Heart Protection Study, reported in 2002, backed up these results. In this study, a statin was given to half of 20,536 subjects with risk factors for heart disease other than a bad LDL cholesterol level. In fact, some of the study volunteers had a relatively good level of LDL (below 116) to begin with. The results showed that cholesterol-lowering statin therapy decreased heart attacks equally in those starting with an LDL level of less than 116 and in those who had a higher initial level of LDL.
In yet another study, published in 2005 and known as the “PROVE-IT trial,” more than 4,000 patients with an elevated LDL cholesterol level who were hospitalized for either a heart attack or unstable angina were given one of two statin drugs and followed for up to 2 years. In one group, LDL levels were decreased to less than 70 mg/dL, as compared with a decrease to about 100 mg/dL in the other group. Those who had their LDL lowered to at least 70 had significantly fewer cardiac events, and there was even further incremental benefit as the LDL was lowered into the 50s and 40s.
Despite these studies, some physicians and researchers believe that using medications to lower cholesterol to very low levels may be dangerous. As far as I’m concerned, there is a danger, but it is from the high levels of cholesterol caused by our modern lifestyle, not the low levels we get by using cholesterol-lowering drugs. Newborns and people living in most preindustrial societies have a “normal” total cholesterol level of 120 mg/dL or less. In the United States, our “normal” is about 200 mg/dL. From my perspective, one could say that aggressive statin therapy simply reduces cholesterol to “natural” levels.
WOULD YOU BENEFIT FROM TAKING A STATIN?
How do you know if you would benef it from taking a statin or another cholesterol-lowering medication? This is something you will need to discuss with your doctor. In my practice, I lower my patients’ cholesterol levels until I believe I have arrested or reversed the underlying disease. The ultimate level, of course, varies from patient to patient. One patient with an LDL cholesterol of 160 mg/dL might have little or no plaque and not require a statin. Another with the very same cholesterol level but a more significant amount of plaque might benefit from aggressive statin treatment.
However, you can get some idea of what your doctor might advise by referring to the NCEP guidelines for LDL cholesterol on page 64. As you can see, the higher your LDL level, the greater your risk of having a heart attack or stroke. (You are at the highest risk if you have diabetes or known heart disease.)
POLYPHARMACY:
PRESCRIBING MULTIPLE MEDICATIONS
Years ago, during my training, I heard a story about using multiple medications to treat a patient with heart disease. It involved Sam Levine, MD, one of the most famous cardiologists of the 1950s and a medical consultant to President Eisenhower’s physicians. As the story goes, Dr. Levine was making teaching rounds one day with his usual entourage. After an intern finished presenting a patient who was on many medications, Dr. Levine turned to leave with the parting words, “Stop all but one.” The intern chased after him, asking, “But which one, Doctor?” To which Levine replied, “Any one.” This skepticism toward the use of multiple drugs was common back then. And for good reason. The small number of medications we had for treating heart disease (and many other diseases as well) tended to be of limited value. Many of the drugs had serious side effects, especially at the maximum doses often given. And when used in combination, the likelihood of experiencing those side effects only multiplied. But they were the only choices at the time.
Today I can choose from literally scores of medications that are both safe and wonderfully effective. Often we use them in combinations so that the patient takes lower, safer, and better-tolerated doses of each individual drug. Most people at high risk for heart disease or stroke do take more than one medication. In fact, some people may take five or six or more. Critics are quick to call this overmedication, and there is indeed some cause for concern.
However, when medications are judiciously prescribed and carefully monitored, a polypharmacy approach can save lives. This is especially true when it comes to treating atherosclerosis. As you have learned, atherosclerosis is a complex disease that is influenced by a host of factors, including heredity, diet, exercise, and stress. This is one of the reasons why understanding how to treat the disease has taken so long. But the fact that it is so complex has an upside. It gives us a lot of targets for treatment, from lowering LDL cholesterol to slowing blood clot formation.
When people take medications that attack atherosclerosis on a number of different fronts, their chances of surviving and maintaining good heart function greatly improve. The Scandinavian Simvastatin Survival Study that I mentioned earlier also demonstrated this. According to a review in the Cleveland Clinic Journal of Medicine, study participants with coronary artery disease were given a variety of treatments. Researchers found that those who were given no medications at all had a 29 percent risk of dying or having a heart attack, stroke, or some other major event within 5 years. Not very good odds. Those who were given statins had a much lower, 18.6 percent, risk. Patients given a statin and aspirin had their risk lowered even more, to 11.2 percent. The lucky ones were those who were given a statin, aspirin, and a medication called a beta-blocker to lower blood pressure. Their risk of a major cardiac event was only 8.6 percent. A later study showed that adding yet another drug, an ACE inhibitor, to this mix resulted in an even greater reduction. A review of this data published in the Cleveland Clinic Journal of Medicine estimated that the cumulative reduction would be 70 percent.
The other advantage of polypharmacy therapy is the ability to keep the dosage of each medication below the level where it is likely to cause side effects. We did not always have this luxury. In my early days in training, we had a small fraction of the pharmaceutical choices we have today. We often had to push medications to the limit of tolerance to control blood pressure or treat other problems. For example, beta-blockers were often prescribed at high dosages for the treatment of blood pressure, angina, or abnormal heart rhythms. Patients were often extremely fatigued at the doses used. Today, we can take advantage of the therapeutic effects of beta-blockers but avoid their side effects by combining them with other medications.
I am well aware that taking multiple medications can be expensive. I also know that keeping so many prescriptions filled and remembering to take medications at the proper time can be annoying. But when the medications are medically necessary, the reward can be life itself.
Because taking multiple medications can have many benefits, two researchers from England and New Zealand made a bold proposal in the British Medical Journal in 2003. They suggested that a “polypill” be created and recommended for everyone over the age of 55. This polypill would combine six generic heart medications, each one having been proven to reduce the risk of heart disease and stroke. According to their calculations, “The Polypill strategy, based on a single daily pill containing six components as specified, would prevent 88 percent of heart attacks and 80 percent of strokes. About 1 in 3 people would directly benefit, each, on average, gaining 11 to 12 years of life without a heart attack or stroke (20 years in those aged 55–64).” The researchers estimated that the polypill would save about 200,000 lives a year in Britain alone.
I don’t think the polypill is such a bad idea, but I think we can do better by tailoring medications to each individual’s risk profile.
IT CAN’T SAVE YOUR LIFE IF YOU DON’T TAKE IT
Almost daily, I find myself talking to a patient about the importance of taking the medications I recommend exactly as I have prescribed them. A few patients never fill their prescriptions. Others take their medications, but are eager to discontinue them because they have the understandable wish to be heart healthy and drug free.
Recently, I saw a new patient who was recovering from a heart attack. He told me that his previous doctor had put him on four different medications. “He gave me a statin, two kinds of high blood pressure medications, and a blood thinner that’s really a rat poison. Well, I stopped taking them all 2 months ago,” he said with a note of pride. “And I feel better now than I did when I was taking them.” I explained to him that by stopping the medications, he was now right back to where he was before the heart attack.
While this scenario is common, a perhaps more troubling reason that people don’t want to take heart medications is that they don’t realize that atherosclerosis is a chronic condition. They think that once they’ve recovered from a heart attack or stroke or had bypass surgery or a stent put in, the underlying problem is gone. In a recent survey of heart attack victims, 41 percent did not know that they were battling a lifelong problem. Nor did they understand that they had a very high risk of having another cardiac event. Without aggressive medical treatment, most people with atherosclerosis eventually die from it. But when patients are treated aggressively—and for many people that includes taking multiple medications—they have a good chance of living to a ripe old age.
I have had a few high-risk patients who were dead set against taking prescription medications of any kind, despite my best attempts to explain why I thought they were necessary. Scott was one of them. Scott had a strong family history of heart disease. His father, grandfather, and two uncles had all died of heart problems before the age of 50. Scott was 53 years old when I first saw him, so he had managed to outlive all of his relatives by several years. This was undoubtedly because he was very conscientious about his diet and had been running 25 miles a week since his midthirties.
To see if his health campaign was truly working, I ordered advanced blood tests and a CT scan. Unfortunately, the scan showed that his genes were carrying on the family tradition: Despite his best efforts, he had a high Calcium Score for his age. The blood tests helped explain why his healthy habits had failed to protect him. First, he had high levels of lipoprotein (a), or Lp(a), an inherited risk factor that does not respond to diet or exercise. (As I discussed in Chapter 4, Lp(a) is the substance that helps LDL particles burrow into blood vessel walls, setting the stage for a heart attack.)
The second problem was that Scott’s good HDL was only 42. Because he was an avid runner, it should have been in the 60s or higher. This was another indication that his genes were defeating his best efforts. Finally, he also had high levels of C-reactive protein (CRP), another risk factor for heart disease (see pages 56–57). To lower these risk factors, I recommended that he take niacin to reduce the Lp(a) and that he also take a statin to reduce his LDL further and to reduce the inflammation indicated by the elevated CRP.
Scott refused to take the statin. He was determined to stay healthy through natural means alone. He agreed to try the niacin only because, as he put it, “It isn’t a drug.” I cautioned him that the niacin might cause skin flushes, a common reaction, but that they would diminish over time. He tried the niacin for a few days and then stopped taking it. “I don’t like the way it makes me feel,” he told me during his next visit.
I can advise my patients about what to do, but I can’t make them comply. Ultimately, the course of Scott’s treatment was up to him, and his choice was to go “all natural.” I made one more plea. I cautioned, “Given all that you’re battling, the natural consequence of relying on all-natural remedies is a premature death.” He told me that he would be even more careful about what he ate and run 40 miles a week. He was going to be so fit that death couldn’t catch him.
I was concerned but not surprised when I got a call from Mount Sinai Hospital about 2 years later informing me that Scott had been admitted to the emergency room. He had been jogging over the Rickenbacker Causeway from Miami to Key Biscayne when he experienced chest pains. He was taken to the emergency room and diagnosed with unstable angina, a sign that a heart attack could be imminent. Later that day, he underwent angioplasty. The good news was that he hadn’t suffered an actual heart attack. His was a classic example of acute coronary syndrome in which a plaque rupture caused severe chest pain but not a heart attack itself. Scott was one of those lucky people who receive a warning signal before a heart attack occurs.
The scare convinced Scott that he really did need to take medications to overcome his bad genes. Today, he takes niacin along with a statin, and I am pleased to report that he continues his healthy lifestyle habits. Chances are good that he will be the first male in his family for several generations to experience old age. Much of the credit goes to him for his own efforts, but credit is also owed to the heart medications that are taking care of the risk factors he cannot change. When a healthy lifestyle is combined with state-of-the-art diagnosis and appropriate medications, even a strong family history of heart disease can be overcome.
“My Calcium Score was over 1,000!”
My mother had a heart attack at 43. She died from heart failure 2 years later. My dad’s brother died from a heart attack at an early age, and my dad had a stroke when he was 63. I was really worried that something would happen to me, especially when I was 42 and 43. But when I turned 44, I lost some of the fear and did kind of a U-turn. I let my guard down for a few years and started eating and drinking whatever I wanted. I gained weight and my blood pressure went up. I was heading down the wrong road. That’s when I read a magazine article about heart scans and decided to track Dr. Agatston down.
The doctor did several tests, including a heart scan and a carotid ultrasound, and then gave me the results. There was good news and bad news. The good news was that my total cholesterol was 190. The bad news was that I had a bunch of plaque in all three of my major coronary arteries and the carotid arteries supplying my brain. I saw the actual images. I had a lot of plaque. My Calcium Score was over 1,000! He told me the reason I had low total cholesterol but lots of plaque was that I had these small cholesterol particles that were just the right size to squeeze into my artery walls. It made sense. So, I had to accept the fact that, although I was only 46, I was a candidate for a heart attack or a stroke.
Dr. Agatston told me that I needed aggressive drug therapy. I believed that drug therapy fuels the pharmacies of America, so I was resistant. I wanted to do it with diet alone. But I tell you, once you see a picture of your own heart and see all the plaque light up, you become a believer. My arteries looked like an airport runway at night, and on the scan, healthy arteries are supposed to look dark. So, I accepted the new game plan—diet, exercise, and drugs.
I still bug Dr. Agatston about allowing me to wean myself off the drugs. But he says that as long as I tolerate my medications and there is no sign of increasing plaque, he wants me to stay on the program. He reminded me that the goal was to keep me alive, not get me off medications. I keep seeing the picture of my clogged arteries, and I totally agree. ■