Cholesterol Update

In the practice of plastic surgery, we are always in a position of evaluating our patients for upcoming surgery. This includes a total medical workup and certainly an analysis of all the drugs that the patients are taking. This matters because when we give anesthesia in order to accomplish a procedure, we need to know what drugs might interact with the heart, kidneys, or clotting of the blood during the procedure.

Interestingly, about every third or fourth patient these days seems to either be on statin drugs or has been requested by their primary care physician to go on them. As you no doubt have read over the past several years, there is some controversy about whether to take these drugs or not, the indications for them, and what they actually do for you or to you. Most of the patients who are on them or have had that proposed to them have a cholesterol level that is elevated about 200 or above. The question is, what blood cholesterol level makes it important to consider taking statins or making changes to your lifestyle habits?

There have been a lot of studies done involving large population groups. In one study, healthy men with high cholesterol levels were studied in an analysis of 11 different clinical trials involving 65,000 persons with 245,000 person-years. The long-term follow-up showed no reduction in mortality when taking statins. This means that 65,000 people received years of statin drug therapy without any reduction in their mortality, which basically means that there is the possibility that the drug did nothing for them but readjust their cholesterol levels. It was also noted in the Journal of the AMA in April 2012 that “It is well established that industry-sponsored drug trials are more likely than non-industry sponsored drug trials to report favorable results of the study because of biased reporting of trial results.” Does this mean that statins were not effective in preventing heart disease and death, or does it mean that the number of deaths presented was small but definite?

The next thing to look at is what side effects are related to preventive statin therapy in people who are healthy. No matter what drugs are used to help prevent cardiac problems, there can be some negative reaction associated with them. Most drugs, even aspirin, can be very helpful, but can cause bleeding and even be responsible for gastrointestinal bleeding or in rare instances death. Taking statins can cause myopathy (muscle weakness and pain), and this is said to be around 5 percent. Also, memory problems and depression can be associated with statins.

Many of the randomized trials excluded from the study patients who had adverse effects of their initial treatment. In one such study, 16 percent of patients were excluded before the study even started because they had muscular pains, renal problems, or liver problems. A study of 2 million statin users in Great Britain showed that it could be associated with increased risk of serious liver dysfunction, acute renal failure, moderate or serious myopathy, and cataracts. There is also a risk of developing diabetes, which was higher for women than it was for men.

Since statins are taken to lower cholesterol, it is good to know which cholesterol levels indicate a risk for prevention of heart disease. In past studies, the ratio of LDL/HDL and cholesterol/HDL could help determine risk levels. The newer concepts of risk include specific studies of sub-segments of serum cholesterol including apoA (larger cholesterol good particles) and apoB (small particles). The ratio of these indicates the risk level for a patient and tells whether taking statins might be of some value. In the cholesterol profile lab tests, LDL-C (good particles) and LDL-P (small dense particles) help evaluate risk levels. Elevated cholesterol alone is not necessarily an indication to take statins, but the LDL-C/LDL-P apoA/apoB ratio might well be more specific. However, treating only a person’s cholesterol level without changing other risk factors is statistically not very effective at all in reducing mortality.

Other risk factors for heart disease include elevated blood sugar, insulin resistance, increased insulin levels, hypertension, Type II diabetes, increased C-reactive protein, elevated homocysteine, overweight, and genetic background. The cholesterol level alone is only one risk factor, and this can be improved by reducing sugar, bread, baked goods, and processed foods, all of which increase blood sugar, insulin levels, and risk of diabetes.

If your doctor suggests that you take statins, remember that they will only improve your cardiac risk a small amount and that with lifestyle and diet changes you can do so much more without the risk of the drug’s side effects. If you are unable to comply with these diet and lifestyle changes, then statins, niacin, and diabetic medication may be the treatment of choice for you. Your physician can explain all of this to you if he thinks that you need to take a statin drug, and he can perform some of the more recent lab tests which can better determine your risk level.

So, if statins are prescribed for you by your doctor, there should be a clear clinical indication for this which will outweigh the negative aspects of taking statins. According to the article in the Journal of the AMA, a healthy person with an elevated cholesterol will not live any longer if he or she takes statins. In a large group, taking statins may prevent myocardial infarction in a small number of patients, but some patients will develop diabetes and 5-20 perecent will experience muscle weakness, fatigue, and memory loss, and all-cause mortality will most likely be the same.  

Lifestyle changes can improve health, longevity, libido, your overall appearance, and your sense of well-being. There are some cases in which taking statins is very useful to reduce the risk of heart disease, but now we have tests that can more accurately determine your risk level than just your cholesterol number alone.

Dr. Carraway is the director of the Plastic & Cosmetic Surgery Center of EVMS. Call 757-557-0300 for more information.

James H. Carraway, M.D.

Dr. James Carraway is a full-time academic and practicing clinical plastic surgeon.  He is Director of the Cosmetic & Plastic Surgery Center of EVMS, is board certified in surgery and plastic surgery, and is a fellow of the American College of Surgeons.  Dr. Carraway has been teaching and practicing for 30+ years and has been director and chairman of residency training programs and fellowship programs in plastic surgery.
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