The Centers for Disease Control reports that about 610,000 people die of heart disease in the United States every year – that’s 1 in every 4 deaths. Heart disease is the leading cause of death for both men and women. While the media and our elected officials spend their time focused on manufactured or even downright false threats to Americans like caravans of Mexicans and Islamic terrorists, the true threat is staring us in the face and we’ve hardly noticed. For comparison’s sake, in 2016 the number of people in America who died due to terrorism was 68. Cardiovascular disease is the number one threat to the well being of all Americans regardless of political ideology.
Like many concerns, a solution begins with the admission that you have a problem. Well, Houston…and Minneapolis…and Charlotte…we have a problem.
The factors that were used to determine if you have cardiovascular disease includes both behavior and health measures. And not surprisingly, there are no surprises here. It is simple to find out if you are one of the 120 million Americans who have some form of cardiovascular disease. There’s even a handy dandy free checklist online here.
Here are the seven factors:
High blood pressure. Anything 130/80 or above is bad. Seriously, it takes one minute at any drug store to find a kiosk and check your blood pressure.
Cholesterol. Generally speaking, adults should have total cholesterol of less than 200. Your LDL (bad cholesterol) should be under 100 and your HDL (good cholesterol) should be 40 or higher for men and 50 or higher for women. Triglycerides should be less than 149.
Blood sugar. A fasting blood sugar level less than 100 is normal.
Be active. Sitting on the sofa is going to kill you. Get up and move. You don’t need to run a marathon, just move your ass at least 150 minutes per week at a moderate pace. That’s like 20 minutes a day of walking.
Eat better. This one is also easier than you think. Lay off the carbs and added sugars and eat a well-balanced diet that consists of mostly vegetables, fruits, whole grains, and healthy fats. This is not rocket science people.
Lose weight. If you do the above two things (eat better and be active) you don’t have to do anything more to reach this goal.
Stop smoking. Vaping too. Knock it off.
So are you one of the 50 percent of Americans who have some form of cardiovascular disease? The answer is yes if you have high blood pressure, high cholesterol, high blood sugar, or if you smoke, eat like crap, don’t exercise, or carry around some extra weight. Frankly, it’s surprising to me that it’s not more than 50 percent of us.
All this is to say what I’ve said before on this blog — heart disease is 80 percent preventable so dying from heart disease is essentially optional. It’s time to pay attention to your risks and do something about them. There’s no excuse anymore for not knowing your risks. If you are a functioning adult you should be able to rattle off your blood pressure numbers, and your cholesterol and blood sugar levels. If you don’t know your numbers, see your doctor right away and find out. Your life literally depends on it.
Statin drugs, used to lower blood cholesterol, are among the most prescribed drugs in the world. In 2016, according to drug tracker QuintilesIMS Institute, the top-selling Statin in America, rosuvastatin (Crestor), brought in a whopping $4.2 billion for manufacturer AstraZeneca and atorvastatin (Lipitor), was prescribed 106 million times to top the list (it was ranked third behind only ACE Inhibitor lisinopril and thyroid drug levothyroxine). Crestor is currently among the top-selling drugs in the world, and Lipitor is the best-selling prescription drug of all time according to Forbes, raking in $148.7 billion since its approval in 1996. And while Lipitor went generic in the U.S. in 2011, manufacturer Pfizer still generated $1.76 billion in sales in 2016 with most of its sales coming from China and other overseas markets (https://www.fool.com) Any way you look at it, Statins are big business in America and around the globe.
Conventional medical wisdom suggests a direct link between high low-density lipoprotein (LDL) cholesterol and heart disease. The theory is that if you have too much bad cholesterol in your blood, it builds up in the walls of your arteries and over time causes hardening (atherosclerosis) which slows and/or blocks blood flow to and from the heart. This theory has been generally accepted for more than 100 years, culminating with the landmark Framingham Heart Study in the 1950s that among other things “proved” that factors such as smoking, high blood pressure, and high cholesterol were related to heart disease. As the science progressed, cholesterol became more understood and now cholesterol-lowering medicine is a cash cow for drug companies. This is an oversimplification, but suffice it to say there have been entire books written on the issue and we don’t really have the time or space here to delve too deeply into the research. Yet it doesn’t take a trained research scientist to type the words “does cholesterol cause heart disease” into Google and come up with hundreds of articles with conflicting conclusions. It is especially true that in the past few years the number of studies discounting the role of cholesterol in heart disease has increased substantially. Honestly, trying to understand cholesterol can give you a heart attack itself. Triglycerides. High-density lipoprotein. Low-density lipoprotein. Very-low-density lipoprotein. Apolipoprotein B.
I don’t know anymore if high cholesterol causes heart attacks. I’m not sure the medical establishment really knows. What I do know is that among the thousands of heart attack survivors in my Facebook support group, hundreds have reported that they did not have high cholesterol at the time of their heart attacks. Others used medication and lifestyle changes to lower their cholesterol and had second or third heart attacks. I had normal cholesterol and exceedingly high triglycerides prior to my heart attack, and both were under control through diet, exercise, and medications at the time of my heart attack. Had the damage already been done in my arteries? Perhaps. I don’t think I’ll ever know. I definitely have both my cholesterol and triglycerides under control now. In fact, as of this writing, my latest blood work showed my total cholesterol was 119, triglycerides 94, HDL cholesterol 41, and LDL 59. This gives me a total cholesterol to HDL ratio of 2.9. These numbers are fantastic by any measure and my primary care doctor, as well as my cardiologist, were very pleased, to say the least. How did I get my numbers to such cardiovascular-friendly levels? Well, I’ve been working on it and experimenting with various medicines, supplements, diet, and exercise. But before I tell you my secret, I must say once again that we are all individuals with different body styles, metabolisms, and, most importantly in my mind, genetic makeup. More than five years after my heart attack, I believe it was caused by years of high triglycerides. Note I used the word believe versus know. Nobody knows for sure why I had a heart attack at age 45, but given my personal history, I have come to believe that my nearly 100 percent blocked LAD was caused by a buildup of plaque due to high triglycerides in my bloodstream. Now I understand this does not account for why I only had a blockage in one artery, given that if in fact, this was the cause other coronary arteries could just as easily have been blocked. Maybe it was random. Or maybe there was something else going on, like inflammation in the LAD that gave the plaque a place to stick.
Regardless, my cholesterol levels were never very high and as you can see from my most recent numbers they are still very low. I was on a Statin prior to my heart attack, but that didn’t stop me from having a heart attack. It’s my understanding that Statins don’t do much to lower triglycerides, nor do they help raise good cholesterol (HDL). So were my doctors wasting my time by putting me on a Statin in the first place? Who knows. When I was first diagnosed with very high triglycerides I was put on a drug called fenofibrate (Tricor) to lower them, and it worked to some degree although while on Tricor they were never as low as they are now.
For the record, it’s my non-scientific belief that the combination of high levels of fish oil, moderate exercise, and a diet extremely low in processed carbs and added sugar has led to my low triglycerides and generally great blood work.
But what about Statins? If lowering LDL cholesterol is so important to the medical establishment shouldn’t we all be on a Statin? There are some doctors who believe this, perhaps most notably Dr. David Agus, professor of medicine at the University of Southern California Keck School of Medicine, who wrote in his New York Times bestselling book The End of Illness that everyone over 40 should discuss Statins with their doctor, even if they haven’t had heart problems or are at increased risk for heart disease or diabetes. Unfortunately, this strategy didn’t work for his most famous patient, Steve Jobs, who died of pancreatic cancer. Nevertheless, the anti-Statin forces are loud, so much so that some doctors are warning that the anti-Statin movement could actually be killing people.
“An internet-driven cult is attacking the safety and effectiveness of cholesterol-lowering Statins, despite mounds of clinical trial data showing the drugs work and produce minimal side effects,”
Dr. Steven Nissen, chairman of cardiovascular medicine at the Cleveland Clinic, told CBS News in 2017.
The anti-Statin crowd seems to align around a different cause of heart disease — inflammation. In fact, more and more it seems the medical community is lining up on one side or another in this debate about cholesterol vs inflammation. One popular inflammation argument, championed by Scottish doctor and author of The Great Cholesterol Con Dr. Malcolm Kendrick, goes like this:
“Chronic stress leads to dysfunction of the hypothalamic pituitary adrenal axis (HPA-axis) which leads to sympathetic overdrive plus added raised stress hormones leads to metabolic syndrome (raised BP, raised blood sugar, raised clotting factors, raised cortisol, raised all sorts of things) which causes endothelial damage plus increased blood clotting which leads to plaque formation and death from acute clot formation.”
Sounds reasonable, yes?
While the great cholesterol debate continues, millions of us remain on Statins and avoid high cholesterol foods, and it may not be doing anything at all to rid us of the number one cause of death in the world.
One thing we can say about cholesterol-lowering drugs like Statins is that they do in fact lower LDL cholesterol. There are hundreds if not thousands of studies to back these claims, so if you want to lower your LDL you should probably be on a Statin. I take a small dose of Crestor every day and my LDL is well below the danger zone. Common cholesterol-lowering drugs include:
Statins such as atorvastatin (Lipitor), pravastatin sodium (Pravachol), and simvastatin (Zocor)
Bile acid resins such as cholestyramine
Cholesterol absorption inhibitors such as ezetimibe (Zetia)
The Statin debate might be very different though if the drugs didn’t have such high reported rates of side effects. Common side effects include muscle pain and damage, liver damage, increased blood sugar or type 2 diabetes and memory loss or confusion. Perhaps these side effects are so widely reported because so many of us take Statin drugs, but perhaps they really do cause rough side effects in many people. I can tell you that no issue is more common in my Facebook support group than Statin side effects and the Internet is awash with people in chat rooms and on message boards complaining about Statin drugs.
It’s probably also worth mentioning that recently the American Food and Drug Administration approved a new type of cholesterol-lowering drug called evolocumab (Repatha) which has been hailed as a “breakthrough” to reduce LDL cholesterol without the side effects of Statins. No doubt, any advancement in cholesterol reduction is going to be big business and Repatha maker Amgen is counting on a huge windfall once the drug is more readily available. By the way, as for the side effect debate, even Amgen warns that Reptha’s side effects include: a runny nose, sore throat, symptoms of the common cold, flu or flu-like symptoms, back pain, high blood sugar levels (diabetes), and redness, pain, or bruising at the injection site.
Many of the survivors I speak to say their goal is to change their lifestyle so that they eventually can stop taking so many drugs. I have a slightly different attitude — I’m grateful for the science that led to these life-saving drugs. Yes, there are side effects and as science progresses we will likely find new therapies and maybe even debunk some current therapies. And while I agree that lifestyle changes are critical to post-heart attack health and well being, I’m fine chugging down a plethora of pills every day.
The bottom line for me is that I’m not so sure high cholesterol causes heart disease. And I definitely don’t think dietary cholesterol raises one’s cholesterol (I think sugar and carbs are the culprit). I’m all in on including healthy fat in my diet, and I have no problem eating eggs and other high cholesterol foods. That said, I don’t have any side effects from my Statin so unless the medical establishment publishes new clear-cut proof I don’t need it I’m going to keep taking it. Yep, hedging that bet a bit.
We all know that elevated cholesterol is an indicator of heart disease risk, but the truth is most of us have no idea what our cholesterol data tells us. Even if you’ve been a good steward of your heart health and have your cholesterol checked regularly, most doctors only tell you the basic results of your blood tests — and that doesn’t tell the whole picture.
You probably know your total cholesterol level, and perhaps you even know that the Centers for Disease Control and other medical experts suggest your total cholesterol should be less than 200 mg/dL. This common wisdom also suggests that your LDL (“bad” cholesterol) should be less than 100 mg/dL, your HDL (“good” cholesterol) should be 40 mg/dL or higher and your triglycerides should be less than 150 mg/dL.
Too often we look at our total cholesterol number and if it’s under 200 we figure we’re fine. Unfortunately, I can tell you hundreds of stories about seemingly “healthy” people who had cholesterol levels under 200 and still had a heart attack. Myself included.
So if these numbers don’t tell the whole picture, what’s a better indicator of your cholesterol-related health? Well, a study published in the American Heart Association journal Circulation found that those people with the highest triglyceride-to-HDL cholesterol ratios had a sixteen times greater risk of heart disease than those with the lowest ratios.
Why? It turns out not all LDL cholesterol is the same, so just knowing your LDL number doesn’t tell you much. In fact, LDL particle size is a much better predictor of heart disease. Some LDLs are large and fluffy while other LDLs are small and sticky. The small sticky cholesterol plays a more critical role in determining your cardiovascular health and it turns out a higher triglyceride to HDL ratio is more indicative of small sticky LDL.
The triglyceride to HDL ratio also indirectly measures insulin resistance, and that is a predictor of diabetes — and diabetes is also a major risk factor for heart disease.
Ideally, you want no more than a 2:1 ratio of triglycerides to HDL cholesterol. So, if your triglycerides are 100 mg/dl, your HDL cholesterol should be 50 mg/dl. — Dr. Stephen Sinatra, cardiologist
It turns out a better strategy for lowering your risk for heart disease is to lower your triglycerides and/or raise your HDL. Ironically, the first line of defense for elevated cholesterol recommended by most cardiologists is a statin to lower your LDL. But statins don’t affect your triglycerides to HDL ratio.
It’s also possible to get a newer type of blood test that measures particle size. The Vertical Auto Profile (VAP) test or a similar test is available at most labs and can give you a sense of whether you are one of the unlucky ones who create small sticky (known as pattern B) cholesterol. Here’s a pretty good explanation of why VAP is better. The site suggests the standard cholesterol test fails to identify as many as 60% of people who are at risk for cardiovascular disease.
Cholesterol is much more complicated than a single number. Don’t let that total cholesterol number fool you into complacency. If you have other risk factors (like diabetes, high blood pressure, elevated blood sugar, family history of heart disease) you shouldn’t assume your total cholesterol number or even your LDL number means you’re safe. Check out your triglycerides to HDL ratio and ask your doctor for an advanced cholesterol test.
Oh, and as I’ve mentioned before, if you have these risk factors you might consider having a coronary artery scan as well.