Category: Statins

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Heart Attacks Heart Health Hyperlipidemia Statins

apoB and Cardiovascular Disease

Most clients in our Heart Health practice show up with their lipid profile in hand, most concerned about their LDL and HDL numbers. In this article, we’ll share our viewpoint on apoB and cardiovascular disease risk.

Old, Discarded Viewpoints

Lipidologists and preventative cardiologists no longer rely on LDL-C as a way to risk stratify someone for heart disease.

In most laboratories, LDL-C is often calculated and rarely measured directly, making LDL-C an even less reliable marker for cardiovascular disease risk.

Once believed to be protective, HDL-C is no longer believed to serve much value when assessing a lipid profile.

Modern Lipid Profile Analysis

If you have one of your old lipid profiles lying around, you can calculate your non-HDL cholesterol, which, 97% of the time, corresponds to apoB levels.

(Total cholesterol) – (HDL cholesterol) = non-HDL cholesterol

You can also use an online calculator.

Triglyceride Levels

these days, we mostly use triglyceride levels to determine if somebody’s dietary intake of simple carbohydrates is excessive.

The higher triglycerides are, or the more insulin resistance somebody is, the more likely they will have excess cholesterol needing transportation by apoB lipoproteins.

apoB Targets

apoB can be cheaply measured ($20 – $60) in most laboratories. Insurance often covers it, but that’s hardly necessary for lab testing.

The way we determine apoB targets is to determine a person’s overall cardiovascular disease risk.

1. Very High Risk

Those at very high risk should have apoB levels below 60 mg/dl.

If apoB isn’t available, their non-HDL-C should be < 90 mg/dl.

From the old LDL-C understanding, the goal would be an LDL-C below 70 mg/dl.

2. High Risk

Those at high risk should have the following numbers with a little more wiggle room compared to someone who is at very high risk:

  • apoB < 75 mg/dl
  • non-HDL-C < 120 mg/dl
  • LDL-C < 100 mg/dl

ApoB and Cardiovascular Disease

The biggest drivers of Atherosclerotic Cardiovascular disease (ASCVD), sometimes also referred to as cardiovascular disease (CVD) are the following:

  • tobacco use
  • hypertension
  • elevated apoB
  • elevated Lp(a)
  • elevated fasting insulin levels

How to Lower apoB

It’s hard to know who responds to what treatment. Some may not be able to tolerate statins even though their apoB drops drastically.

Others may see a massive drop in apoB by changing their diet, especially if they are hyperabsorbers of cholesterol.

Just as we have hyperabsorbers, those whose intestines squeeze every last bit of cholesterol from the food, we have hyperproducers.

The hyperproducers produce a lot of cholesterol from the liver, which finds its way into the circulation, causing elevation of apoB.

These changes partly explain why some will respond well to statins and even better when we add ezetimibe.

Repeat Testing of apoB Lipoproteins

In general, we advise our clients to check their apoB levels annually. As soon as it starts to get out of range, we discuss various interventions.

build a chance of a sudden rise in this lipoprotein level is low, regular monitoring will allow for immediate intervention.

apoB Lowering Through Exercise

When it comes to lowering certain risk factors, blood pressure is quite amenable to lifestyle changes.

It does not seem to be the same case with apoB levels. For those with a high elevation of this molecule, it is always advisable to start with lifestyle modifications first.

And certainly, there are certain dietary changes, such as a very low-fat diet, that can greatly improve someone’s apoB levels. Unfortunately, this is rarely reachable.

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Heart Health Hyperlipidemia Statins Treatment

Reversing Atherosclerosis

Is it possible to reverse atherosclerosis in the coronary arteries or anywhere else in the body? This topic, often called plaque regression, deserves an overview for anyone considering any Heart Health intervention.

Atherosclerosis – The Approach

It’s fair to say that if you are past your teenage years, you will have some atherosclerosis. This is the plaque buildup inside the arteries of the body which causes health problems mostly when it affects the blood supply to the heart, brain, and limbs.

1. Main Approach – Prevention

The main approach to atherosclerosis is preventing it.

With our Heart Health Coaching, the goal is to live a lifestyle that:

  • decreases blood pressure
  • lowers circulating apoB levels
  • decreases inflammation
  • improves mitochondrial health

For many, lifestyle changes are adequate, and we can track serum biomarkers such as lipid levels, inflammatory markers, and serum insulin levels to track success.

For others, chemical interventions may be necessary, even for the prevention stage, such as statins, ezetimibe, or the PCSK9 inhibitor class of medications.

2. Secondary Approach – Treatment

Some clients will already have an atherosclerosis diagnosis. Perhaps a physician noted it on a knee X-ray, or the patient is experiencing symptoms of angina.

The secondary approach is to help prevent major cardiovascular events (heart attack, strokes, peripheral vascular disease) due to the buildup of this plaque.

Must we reverse atherosclerosis for this secondary approach to be successful?

Plaque Regression

Western Medicine states that not all plaque is equal. We have stable plaque and potentially unstable plaque. Though this is a rough categorization, it’s a helpful mental model to follow.

The goal is to minimize unstable plaque but encourage remodeling of existing unstable plaque and perhaps to encourage plaque regression.

In plaque regression, the amount of plaque actually decreases. Tiny intravascular ultrasound (IVUS) or a CT angiogram (CCTA) can confirm this.

Available studies show that high-intensity statin therapy decreases overall plaque volume by 10%, but that may not fully explain the decreased risk of cardiovascular events. So, perhaps stabilization is just as important.

Stabilization vs. Regression

This summary article determines which is better, stabilization vs. regression of plaque. Of course, in real life, we don’t have to choose one or the other – that’s the headache best left for the researchers.

1. Stabilizing Plaque

MIRACL, PACT, CURE, HOPE, and Lyon support the idea that plaque stabilization is effective.

We know from various studies that a lower-fat diet, increased activity, and managing stress/sleep can stabilize plaque, shifting more toward the preferred calcified plaque.

It’s important to mention that statins tend to change plaque composition toward:

  • fibrous volume
  • calcified plaque
  • reduction in fibrofatty volume
  • decreased a necrotic core

2. Reversing Plaque

ASTEROID, REVERSAL, and SATURN studies, on the other hand, focused on plaque reversal as a way to decrease the risk of cardiovascular disease.

We haven’t come across any convincing studies to demonstrate that plaque regression is necessary to help prevent major cardiovascular events.

However, if plaque regression is the goal, high-dose statin treatment should be the treatment of choice.

This answers the common questions our clients ask us about whether to repeat CT angiograms or CACs.

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Diet Heart Health Hyperlipidemia Prevention Statins Treatment

How the Body Regulates Cholesterol

In this article, I wanted to provide a basic overview of cholesterol regulation in the body. I share such articles with my heart health coaching clients whenever necessary. How the body regulates cholesterol is relevant to choose the right method of controlling cholesterol levels.

Cholesterol Regulation

Cholesterol is quite essential. The following key players regulate cholesterol in the body:

  • cells lining the intestine
  • liver
  • pancreas
  • intestinal bacteria

The food we eat has some form of cholesterol which becomes absorbable after manipulation by intestinal bacteria and pancreatic enzymes.

Cholesterol can enter the bloodstream also through the bile system. Whether you still have a gallbladder or not, your liver will produce cholesterol pumped into the intestines.

Cholesterol Absorption Varies

Some individuals are hypoabsorbers of cholesterol. No matter how much high cholesterol foods they consume, their intestinal cells don’t take up much of it.

Others are hyperabsorbers of cholesterol; even the lightest meals can have every bit of its cholesterol extracted and pumped into the bloodstream.

Cholesterol Regulation and Treatment Options

For my hypoabsorber clients, I am less concerned about their dietary cholesterol intake. Their cholesterol production in the liver would be a more important factor.

The hyperabsorbers will benefit a lot from a particular dietary change. Sometimes it helps to cut back on saturated fats, but eating times and gut bacteria are also important criteria.

Dietary change? Statin therapy? Ezetimibe? Evolocumab?

To answer that, I need more information about the person. A generic cholesterol test won’t always tell us the whole story.

The Liver’s Cholesterol Production

How cholesterol is regulated in the body has a lot to do with the liver. This fleshy organ on the right upper quadrant of the abdomen produces LDL, HDL, and VLDL particles.

Statin drugs decrease the production of cholesterol molecules in the liver.

The liver also has LDL receptors and absorbs cholesterol.

From fatty liver to elevation of liver enzymes to problems with the gallbladder, it’s important to consider the health of this organ when assessing my clients.

The Role of Gut Flora and How Cholesterol is Regulated

Some bacteria in the gut convert free cholesterol molecules into a stanol chemical that intestinal cells cannot absorb.

We could call these beneficial bacteria. They can help slow down the absorption of cholesterol for certain individuals.

Ezetimibe is a medication that works similarly, blocking the absorption of free cholesterol molecules.

Categories
Heart Attacks Heart Health Metabolic Statins

Atherosclerosis and Inflammation

Coronary plaque undergoes a specific transformation that ends up causing a blockage of the vessel and eventual ischemia. In this article, I will discuss the basics of how atherosclerosis and inflammation play a role in heart health.

Atherosclerosis

Plaque is the buildup inside an artery, leading to decreased blood flow and sometimes complete lack of blood flow – obstruction. It begins far deeper in the vessel wall before you see anything protruding through into the lumen of the artery.

With obstruction comes ischemia – lack of oxygen to the nearby tissue, not just muscle but the vessels themselves, the nerves, and connective tissue.

You need cholesterol to form this plaque. With a total cholesterol value below 150, achieved naturally without medications, it’s rare to see someone develop much plaque in their arteries.

Another ingredient for plaque buildup is hardened vessels and increased pressures or turbulent blood flow through those vessels. Hypertension can cause this; lack of exercise or inflammation can also contribute.

Unstable Plaque

Let’s lay the cards flat on the table – we know little about inflammation. Astute clinicians can recognize inflammation when they see it. There are specific biomarkers that are helpful as well.

Inflammation adds to the problem of atherosclerotic and negatively affects heart health because it leads to unstable plaques.

A plaque is like a scab on a wound. If it’s the right time for it to come off, it’ll fall off without any bleeding. Rip it off prematurely, and you’ll get fresh blood.

Fresh blood will clot in the artery and create an unstable plaque that is prone to rupturing and exposing those raw surfaces. Suddenly you go from a tiny plaque to a massive clot that halts all blood flow in that artery.

Measuring Inflammation

Several biomarkers can tell us there is inflammation. But it’s not biomarkers alone we use in our risk stratification.

Some people with inflammation in their bodies may never develop unstable plaque. And some with inflammation may not have much plaque to begin with.

If someone has atherosclerosis, the goal is to increase their exercise capacity – both cardiovascular and anaerobic. Next, we want their systemic inflammation to be as low as possible.

Examples of inflammatory biomarkers are below. Some are nonspecific markers, and others are specific to the atherosclerotic cardiovascular disease.

Atherosclerosis and Inflammation

In regards to heart health, atherosclerosis isn’t a death sentence. Most of us will develop it, and less than half of us will suffer heart attacks or other complications because of it.

Preventing atherosclerosis is what we encourage in our Heart Health program. But most of those who come to us already have atherosclerosis.

Plaque and inflammation have an essential relationship in Heart Health which we address with this second group. We want to decrease their total body inflammation to allow newly formed plaques or old plaques to stabilize.

Statins lower inflammatory markers independent of their lipid-lowering effects. Perhaps this is another reason why they are effective and reducing cardiovascular death.

In a meta-analysis of 26 randomized controlled trials involving over 160,000 participants, statins were shown to reduce the risk of all-cause mortality by 10% and the risk of cardiovascular mortality by 15%.

Other Inflammatory Markers

Even without serology, we can tell if someone has inflammation. More importantly, how much more actionable information do we get beyond the basic inflammatory markers?

The following are inflammatory markers I use based on signs and symptoms:

  • obesity
  • acne
  • rosacea
  • seborrheic dermatitis
  • joint pain
  • fatigue
  • sleep disturbance
  • agitation
  • sound sensitivity
  • GI changes
  • heavy menses
  • concentration issue

As you can imagine, these are rather subjective. Even if you have a little bit of all of this, it doesn’t mean there is inflammation.

We use these data points as a guide. With them, we change our diet and lifestyle and reevaluate. If these markers decrease, then inflammation is likely.

Interventional Steps to Consider

First, where’s the fire? What we mean by this is that the person likely isn’t about to have a heart attack or die from their inflammation.

Let’s figure out why the inflammation is there; stress, insomnia, too much exercise, dairy, wheat, or environmental exposures.

Next, we recommend testing those values, which are the most sensitive markers of inflammation, and see if there was any change.

Nattokinase or curcumin decreases inflammatory markers such as the commonly tested hs-CRP and fibrinogen.

Normal LDL Levels?

Imagine the LDL-C levels of a person are normal. How could we predict what their heart attack and death from heart attack risk would be?

Paul Ridker et al. did a wonderful study highlighting this relationship and showed that hs-CRP would be a bigger predictor of a heart attack or death when a person has normal or even high LDL-C levels.

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Heart Attacks Heart Health Statins

Statins for Heart Disease Prevention

Statins are prescribed either for existing heart disease or to prevent heart disease. Preventing heart disease is referred to as a primary prevention strategy. Let’s discuss if statins for heart disease prevention are as effective as advertised and what other factors one should consider.

Statins to Prevent Heart Disease

Statins have gone through a lot of recommendation changes over the years. Some statins stand out more than others.

But there are still a lot of disagreements when it comes to using statins for the prevention of heart disease. This means using a statin for someone who is otherwise healthy but wants to prevent a heart attack.

In western medicine, it’s the standard of care to prescribe this medication to individuals with high cholesterol or diabetes, hoping it will prevent a heart attack.

The Actual Numbers

Think back to your high school class. Let’s say you had 150 people in that class. If everyone in that class took a statin to prevent a stroke, then only 1 out of 150 would benefit.

In other words, 150 people would have to be treated to prevent 1 stroke. And 100 would have to be treated to prevent 1 heart attack.

We refer to this as the NNT – the number needed to treat.

The Harm of Statins

Fortunately, statins are relatively safe medications. Yes, some people develop terrible side effects with them. Some even can develop diabetes or muscle or liver damage.

Obviously, we wouldn’t prescribe medication unless it was absolutely necessary. If only those who really needed this medication took it, the risk of statins would be far lower than its benefits.

But the actual harms of this medication – 1 in 50 would potentially develop diabetes, and 1 in 10 would develop muscle pains or damage.

Preventing Heart Disease

So what does work if not statins?

Controlling your blood pressure, eating a healthy diet, and maintaining a healthy activity level seems to decrease your risk of a heart attack.

Other factors like stress and cholesterol matter but are closely tied to your diet and activity levels.

The Individual Factor

As a physician, I don’t like talking about medication or an illness in general terms. Each person is unique, and all things matter. I learned this phrase from my functional nutrition course.

Each person is unique, so we must approach each person’s risk factors and decisions individually.

All things matter means that the patient’s individual abilities and lifestyle factors determine what intervention we choose or don’t choose.

Categories
Heart Health Hyperlipidemia Statins

Do Statins Prevent Heart Attacks?

For the right patient, a statin is a lifesaver. But do statins prevent heart attacks? They are used to lower cholesterol levels, but some will still suffer a heart attack even when taking a statin.

It’s essential to understand this concept. You can still suffer a stroke or a heart attack while taking a statin medication.

Primary & Secondary Prevention

Statins are a group of medications such as simvastatin and atorvastatin. There are others, and each has its place in managing serum lipids.

A statin is prescribed to some patients to lower their cholesterol and prevent a heart attack, stroke, or other atherosclerosis-related medical conditions.

This primary prevention strategy is used for those who haven’t yet had a heart attack or stroke. But many will have had such cardiovascular events and be put on a statin – we refer to this as secondary prevention.

Secondary prevention means trying to prevent a second or third heart attack or stroke.

Statins and Heart Attacks

Western medicine’s big gun remains the statin drug. Even with this, nearly 25% of those on a statin still can suffer a heart attack.

I fished this number from a few studies and my personal experience with my patients. Now that even more patients are on statins, this number likely is higher.

Heart disease is a complicated process. Simply lowering your cholesterol isn’t enough to entirely prevent a heart attack. It’s a big step in the right direction – for some.

Preventing a Heart Attack

A statin won’t prevent a heart attack. It will lower a person’s cholesterol. This lower serum lipid profile may slow the progression of atherosclerosis.

A heart attack can happen in those with normal cholesterol levels. This is why it’s essential to address heart health not just from the serum lipid perspective but from a broader angle.

Whether you’ve already had a heart attack or are trying to prevent one in the first place, it’s crucial to figure out what your risk factors are.

Some of us can easily change our diets, and others will have a hard time with diet but can readily improve their exercise capacity. You’ll significantly improve heart health regardless of which strings you pull on.