The holidays bring visions of sugar plum fairies dancing and tables filled with fruitcake, sugar cookies, gingerbread, red velvet cake, macaroons and chocolate yule log. These delectable holiday treats are as much a staple of the holidays as family gatherings and celebrations. Unfortunately, these sugary delights are not quite part of a heart healthy diet and can wreak havoc with cholesterol levels. As we head into the peak holiday and treat-eating season, it’s a good time to review what is new in cholesterol management.
Who should be treated with a statin for high cholesterol in 2019? In 2013, the American Heart Association and the American College of Cardiology published a guideline to address this topic. This guideline was just updated in November 2018, adding more nuance to the original. The guideline focuses primarily on LDL cholesterol (low density lipoprotein, “the bad cholesterol”). In general, there are four categories of patients for whom a statin should be prescribed:
1) secondary prevention (trying to prevent a second event in patients who have already had a heart attack or stroke),
2) diabetic patients (a high risk group) whose LDL is greater than 70 mg/dl,
3) patients with an LDL greater than 190 mg/dl (severe familial high cholesterol). For these three groups, especially secondary prevention, the medical literature is quite consistent in showing the benefit of statin therapy. The data for statins is less robust in the fourth group, primary prevention (trying to prevent a heart attack or stroke in a patient who has not had an event). The 2013 guideline used a risk calculator (which can be found at: cvriskcalculator.com) to identify high-risk patients for primary prevention. This was a controversial issue at the time and many cardiologists felt that the calculator overestimated the risk, thus exposing more people to statin therapy. The updated guideline attempts to clarify who should be on a statin by adding risk enhancers and using coronary calcium score. If the calculator places the patient at high risk for a cardiac event over the next ten years with a score of 20% or greater, then a statin should be given. If the patient is at low risk (a score of 5% or less), then no statin is necessary. If the patient is at intermediate risk (a score between 5% and 20%), then risk enhancers are used. These risk enhancers are:
LDL > 160 mg/dl,
high-sensitivity C reactive protein level (a measure of inflammation) > 2.0 mg/L,
triglycerides > 175 mg/dl,
apoliprotein B level > 130 mg/dl,
lipoprotein (a) level > 50 mg/dl,
peripheral arterial disease,
chronic kidney disease,
chronic inflammatory disease (rheumatoid arthritis, psoriasis, or lupus),
metabolic syndrome (hypertension, diabetes, high triglycerides, obesity- especially a large waist circumference),
family history of premature heart disease, or
premature menopause.
With an intermediate risk score and the presence of one or more risk enhancers, a statin should be prescribed. If the patient and the doctor still are uncertain about starting a statin, then a coronary calcium score can be used. A CT scan of the heart measures the calcium score. Calcium is found in plaque in the heart arteries. The higher the amount of calcium, the more plaque is present in the heart arteries. A coronary calcium score of zero means there is no plaque and a statin can be withheld. However, if the calcium score is 100 or more, then a statin is indicated.
What about the other test on the standard lipid panel, triglycerides? It is well known that patients who have heart disease and good LDL levels on statin but have elevated triglycerides are still at risk for cardiac events. It is thought that reducing triglycerides can provide an additional benefit beyond lowering the LDL. Unfortunately, this hypothesis has never been proven, until recently. Medications that reduce triglycerides such as niacin or fenofibrate, taken with a statin, did not show a reduction in cardiac events. Omega-3 fatty acids (fish oil) are present in fatty fish and in populations with high fish intake, there is a lower risk for heart disease. Formulations of omega-3 fatty acids contain either eicosapentaenoic aicd (EPA) alone or a combination of EPA with docosahexaenoic acid (DHA). These medications are prescribed to treat elevated triglycerides but neither the combination nor low dose EPA have been shown to reduce the risk for heart disease. More recently, a high dose, pure form of EPA was tested in patients with heart disease, statin controlled LDL levels and high triglycerides. For the first time, the pure form EPA was shown to reduce the risk for heart attack, stroke and cardiac death by 25%. The triglycerides were lower in patients on the medication, but it is thought that other mechanisms, such as an anti-inflammatory effect of the EPA, may also have contributed. The results of this trial have changed the way cardiologists view and treat triglycerides in their patients with heart artery disease. Is fish oil beneficial for the primary prevention of heart disease? Two recent trials tested patients without heart disease by using a combination of EPA and DHA. Neither showed a reduction in heart attack, stroke or cardiac death. Therefore, low doses of fish oil are not beneficial for primary prevention but prescription high dose EPA is now being used for secondary prevention of heart disease.
So, enjoy the holidays with friends and family. Have a holiday treat or two. If you want some heart healthy choices (including treats), try the recipes at heart.kumu.org. Then in the New Year, tackle those high cholesterol and triglyceride numbers.
