Protecting the high-risk heart patient

The bad news is that diabetes and other risk factors like high blood pressure and cholesterol, smoking and obesity increase one’s risk of a heart attack by three to six-fold.

The good news is that one can cut this risk remarkably by taking a cholesterol-lowering drug belonging to the statin family…even if one’s cholesterol level is still within normal levels.

Patients who have heart disease shirk at the mere mention of the word cholesterol. In fairness though to cholesterol, it has some good uses in the body. It is a major component of the cells that make up our body tissues and it also maintains the structural integrity of our nerves.

Cholesterol is also the framework for steroid hormones produced in our body. Steroid hormones include the sex hormones and other natural substances in the body essential for metabolism. As insulators, fat tissues help in maintaining the right body temperature by keeping us warm in cold days and cooler in warm days. Equally important is that fats can be used as energy. Stored as fats in our body, they are mobilized and utilized in times of dieting or starvation, and converted into glucose, the energy source of the body, through the process of gluconeogenesis.

Fat reserve

Unfortunately, the ability to be stored as fat reserve is a proverbial double-edged sword. In huge amounts, it can increase weight and lead to obesity. The even bigger concern is that cholesterol can be deposited along the inner lining of the arterial wall, called the endothelium, producing an atherosclerotic plaque.

This atherosclerotic plaque is an aggregate of fat and blood cells sticking in the intima promoting the formation of blood clots, which can cause heart attacks and strokes. The lining covering the plaque can rupture and extrude its fat contents into the circulation triggering blood clot formation. The event can be catastrophic and can be prevented with cholesterol-lowering drugs, even if the blood cholesterol is still within normal levels or just slightly elevated.

This is especially true in high-risk patients, particularly diabetics. Diabetics are considered high-risk and are placed in the same level of risk as those who already had a heart attack and stroke.

Diabetes and elevated cholesterol make a deadly combination and recent landmark trials with the anti-cholesterol drug simvastatin show that diabetics can benefit from this drug even in those with just average or normal cholesterol levels. Some diabetes and heart experts even believe that diabetics should be routinely placed on the class of drugs called statins regardless of their cholesterol levels.

Benefits of statins

At present, statins are often only prescribed to patients who have heart disease and elevated cholesterol levels. But new findings from the 20,000-patient Heart Protection Study (HPS) done in the United Kingdom show that statins also significantly reduce the risks of heart attacks and strokes in people who have diabetes, or have narrowing of arteries in their legs, or have had a stroke.

Something which has not been shown in previous study is that substantial benefits can be expected even among those high-risk patients considered to have "normal" or "low" cholesterol levels. Because of this study, there is now strong evidence that existing treatment guidelines for elevated cholesterol levels should be changed so that – irrespective of the blood cholesterol level – a statin should be considered as standard therapy for anybody at increased risk of either heart attacks or strokes.

The big catch, however, is that statins have to be taken for long periods of time, usually several years, for the high-risk patient to benefit from them. Unfortunately, the cost of statins is beyond the reach of the ordinary wage earner. It may prevent strokes and heart attacks, particularly in diabetics, but it may cost them an arm and a leg trying to afford the P2,000 or P3,000 that will buy a month’s supply of most statins.

We’re calling on the drug companies distributing statins to be more considerate and lower the price of this life-saving drug. We would like to commend Therapharma for taking the initiative of making their simvastatin (Vidastat) available at half the price compared to other brands. We hope the other companies will follow suit.

Checking the blood cholesterol is not enough to have a complete picture of one’s fat status. Also vital in lipid evaluation is determining the triglyceride levels and the fat "transporters" known as High Density Lipoprotein (HDL) and the Low Density Lipoprotein (LDL).

HDL and LDL are popularly called "good" and "bad" cholesterol, respectively, owing to their function. HDL acts as the policeman by checking the level of LDL and eliminating its excess, and works also as a dispatcher by removing excess fats in the body. On the other hand, LDL is the notorious one; it keeps the fat deposits in the body regardless of excess and worse, it even clogs up the arteries.

Although anti-cholesterol drugs may be required in many instances, it cannot be overemphasized that diet and exercise remain the mainstay of combating the ill-effects of cholesterol. These so-called lifestyle changes effectively work if patients can only sustain them.

Exercise, calorie watch

Exercise promotes continuing use of energy of the body, allowing fats to be burned instead of being deposited. It also keeps us trim and in perfect health. Perfect because the body is trained to adapt or adjust by training its compensatory mechanisms, to adjust to the rigors of exercise. For example, exercise teaches the blood vessels to continually dilate or constrict depending on the amount of blood needed to sustain a good blood flow. It is beneficial because it can tap all the dormant muscles into action, keeping them in good tone. The physical stress allows adequate gaseous exchange, thus replenishing the carbon dioxide in our lungs with fresh air.

Monitoring the calories we take in and restricting fats to less than 30 percent will keep cholesterol at bay. Realistically though, it’s hard to calculate and monitor our calorie count. The simple way is to add more vegetables and fruits to our diet.

Fibers promote elimination of bad cholesterol from our food. Taking oats, beans, peas, fresh fruits and vegetables with "psyllium" lowers LDL and increases HDL. Soy foods and its derivative soy drinks and tofu can lower the cholesterol level. However, soy is also high in uric acid that can trigger gouty arthritis attacks. Given a choice though between high cholesterol and high uric acid, I think the latter is the lesser of the two evils.

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(The author is a consultant on emergency medicine at the Manila Adventist Medical Center.)