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Saturday, April 27, 2019

Cholesterol and statins: it’s no longer just about the numbers

Last year, new guidelines from the American Heart Association, the American College of Cardiology, and nine other health organizations lowered the numbers for the diagnosis of hypertension (high blood pressure) to 130/80 millimeters of mercury (mm Hg) and higher for all adults. The previous guidelines set the threshold at 140/90 mm Hg for people younger than age 65 and 150/80 mm Hg for those ages 65 and older.

This means 70% to 79% of men ages 55 and older are now classified as having hypertension. That includes many men whose blood pressure had previously been considered healthy. Why the change?
Behind the numbers

"Blood pressure guidelines are not updated at regular intervals. Instead, they are changed when sufficient new evidence suggests the old ones weren't accurate or relevant anymore," says Dr. Paul Conlin, an endocrinologist with Harvard-affiliated VA Boston Healthcare System and Brigham and Women's Hospital. "The goal now with the new guidelines is to help people address high blood pressure — and the problems that may accompany it like heart attack and stroke — much earlier."

Discover the secrets to lowering your blood pressure and reducing your risk of heart attack, stroke, and dementia!

The new guidelines stem from the 2017 results of the Systolic Blood Pressure Intervention Trial (SPRINT), which studied more than 9,000 adults ages 50 and older who had systolic blood pressure (the top number in a reading) of 130 mm Hg or higher and at least one risk factor for cardiovascular disease. The study's aim was to find out whether treating blood pressure to lower the systolic number to 120 mm Hg or less was superior to the standard target of 140 mm Hg or less. The results found that targeting a systolic pressure of no more than 120 mm Hg reduced the chance of heart attacks, heart failure, or stroke over a three-year period.
More than blood pressure

The new guidelines have other changes, too. First, they don't offer different recommendations for people younger or older than age 65. "This is because the SPRINT study looked at all patients regardless of age, and didn't break down groups above or below a certain age," says Dr. Conlin.

The guidelines also redefined the various categories of hypertension. It eliminated the category of prehypertension, which had been defined as systolic blood pressure of 120 to 139 mm Hg or diastolic pressure (the lower number in a reading) of 80 to 89 mm Hg. Instead, people with those readings are now categorized as having either elevated pressure (120 to 129 systolic and less than 80 diastolic) or Stage 1 hypertension (130 to 139 systolic or 80 to 89 diastolic).

A reading of 140/90 mm Hg or higher is considered Stage 2 hypertension, and anything higher than 180/120 mm Hg is hypertensive crisis.
Check your blood pressure at home

The new guidelines note that blood pressure should be measured on a regular basis and encourage people to use home blood pressure monitors. Monitors can range from $40 to $100 on average, but your insurance may cover part or all of the cost. Measure your blood pressure a few times a week and see your doctor if you notice any significant changes. Here are some tips on how to choose and use a monitor.

Choosing

    Select a monitor that goes around your upper arm. Wrist and finger monitors are not as precise.

    Select an automated monitor, which has a cuff that inflates itself.

    Look for a digital readout that is large and bright enough to see clearly.

    Consider a monitor that also plugs into your smartphone to transfer the readings to an app, which then creates a graph of your progress. Some devices can send readings wirelessly to your phone.

Using

    Avoid caffeinated or alcoholic beverages 30 minutes beforehand.

    Sit quietly for five minutes with your back supported and your legs uncrossed.

    Support your arm so your elbow is at or near heart level.

    Wrap the cuff over bare skin.

    Don't talk during the measurement.

    Leave the deflated cuff in place, wait a minute, then take a second reading. If the readings are close, average them. If not, repeat again and average the three readings.

    Keep a record of your blood pressure readings, including the time of day.

What should you do?

If you had previously been diagnosed with high blood pressure, the new guidelines don't affect you too much, says Dr. Conlin, as you still need to continue your efforts to lower it through medication, diet, exercise, and weight loss. "However, based on new information in the guidelines, your doctor may propose treating your blood pressure to a lower level," he says.

The larger issue is that many men ages 65 and older suddenly find themselves diagnosed with elevated or high blood pressure, since the new normal is a whopping 20 points lower than before. Does this mean an automatic prescription for blood pressure drugs? Not necessarily.

"They should consult with their doctor about first adjusting lifestyle habits, such as getting more exercise, losing weight, and following a heart-healthy diet like the DASH or Mediterranean diet," says Dr. Conlin.

Medications are recommended to lower blood pressure in Stage 1 hypertension if you've already had a heart attack or stroke or if your 10-year risk of a heart attack is higher than 10%. (You can find your 10-year estimation at www.cvriskcalculator.com.) For others with Stage 1 hypertension, lifestyle changes alone are recommended. Overeating during the holidays is practically a tradition. “We rationalize that it’s a special time, with foods that aren’t available throughout the year,” says registered dietitian Kathy McManus, director of the Department of Nutrition at Harvard-affiliated Brigham and Women’s Hospital. But overindulging can lead to weight gain, fatigue, and guilt. So how should you approach the holiday buffet? Here are some tactical strategies to get you through the season of eating.

Plan ahead. Find out when you’ll be eating, and plan your day around it. For example, if you know a big dinner will be served at 8 p.m., eat a lighter breakfast and lunch than usual. But also have a healthy snack just before you leave home at 6 p.m. so that you don’t arrive at the party feeling hungry; otherwise you’ll overeat.

Also, ask if you can bring a dish for the buffet. If the answer is “yes,” bring something healthy, such as chicken and veggie skewers or an assortment of fruit.

At the buffet. Grab a salad plate instead of a dinner plate. You’ll fool yourself into maintaining portion control. Avoid foods that are fried, buttered, creamy, or cheesy. Load at least half of your plate with veggies, then add just a taste of other foods. But choose wisely; don’t waste calories on foods that aren’t special. For example, a roll with butter can easily add 200 calories.

At the table. Research shows you’ll eat less food and take in fewer calories if you eat slowly, so pace yourself at holiday meals. Do this by taking small bites, chewing slowly, and sipping water between bites. When you’ve finished, don’t linger at the table, which may encourage more eating. The reason to eat slowly is that it takes at least 20 minutes for your brain to get the message that you’re full. It’s easy to consume many more calories than you need in 20 minutes. In fact, you can consume all the calories you need for a whole day in 20 minutes.

About alcohol. Alcohol adds calories in a hurry, and it can ruin your resolve. McManus advises that you delay drinking until you begin your meal. Set a limit in advance, and ask your host or buddy for help observing the rule.

If all else fails. When temptation trumps resolve, don’t beat yourself up, and don’t feel you’ve failed. Just go back to a healthy eating plan as soon as possible. “Don’t feel guilty about food,” says McManus. “It’s there to enjoy. But you must give your meals some thought.” Think of this planning as a little gift you give yourself. Updated cholesterol guidelines released yesterday by the American Heart Association and American College of Cardiology aim to prevent more heart attacks and strokes than ever. How? By increasing  the number of Americans who take a cholesterol-lowering statin.

The previous guidelines, published in 2002, focused mainly on “the numbers”—starting cholesterol levels and post-treatment levels. The new guidelines focus instead on an individual’s risk of having a heart attack or stroke. The higher the risk, the greater the potential benefit from a statin.

Statins are a family of medications that lower cholesterol. Even more important, they lower the chances of having a heart attack or stroke. Statins include atorvastatin (generic, Lipitor), fluvastatin (generic, Lescol), lovastatin (generic, Mevacor), pitavastatin (Livalo), pravastatin (generic, Pravachol), rosuvastatin (Crestor), and simvastatin (generic, Zocor). The new guidelines recommend a statin for:

    anyone who has cardiovascular disease, including angina (chest pain with exercise or stress), a previous heart attack or stroke, or other related conditions
    anyone with a very high level of harmful LDL cholesterol (generally an LDL above greater than 190 milligrams per deciliter of blood [mg/dL])
    anyone with diabetes between the ages of 40 and 75 years
    anyone with a greater than 7.5% chance of having a heart attack or stroke or developing other form of cardiovascular disease in the next 10 years.

How is this different from the previous guidelines? They recommended specific cholesterol targets for treatment. For example, people with heart disease were urged to get their LDL cholesterol down to 70 mg/dL. The new guidelines essentially remove the targets and recommend basing treatment decisions on a person’s heart risk profile.

In other words, anyone at high enough risk who stands to benefit from a statin should be taking one. It doesn’t matter so much what his or her actual cholesterol level is to begin with. And there’s no proof that an LDL cholesterol of 70 mg/dL is better than 80 or 90 mg/dL. What’s important is taking the right dose based on heart attack and stroke risk.

There are a few reasons for these new “risk-focused” guidelines:

    Statins are the best drugs to lower LDL cholesterol.
    Statins also have benefits above and beyond cholesterol lowering. We have long known that statins lower the risk of premature death, heart attack, and stroke, even among individuals with relatively normal cholesterol levels—who are not exempt from having heart attacks or stroke.
     A statin dose tailored to the individual appears to be more important than reaching a particular target number.

Putting guidelines into practice

Will these guidelines change how your doctor checks and treats your cholesterol? Yes and no. Many physicians are already focusing on the balance of benefits and risks when making decisions about treatment. I, for one, am already prescribing statins to patients of mine at high risk of heart disease even when their cholesterol levels are close to normal. What will be new for me is making sure my patients are on an effective dose and no longer focusing on how low their LDL drops.

These new guidelines, while meant for doctors, contain a lot that each of us can do. Here are some examples.

    Go beyond the numbers. When talking with your doctor, instead of focusing on your cholesterol “number,” ask about your risk for developing cardiovascular risk. That appears to be a better guide as to whether you should be on a statin. Your doctor should have tools to help you estimate that. The new AHA/ACC guidelines recommend replacing the Framingham Risk Score with a new way to estimate risk.
    Consider the risks. No treatment is without some risk. Statins can cause muscle pain, and in a small number of individuals, more significant muscle injury and rarely liver problems. They have also been associated with increases in blood sugar, which in some cases leads to a diagnosis of diabetes. Some reports have linked statin use to memory issues, but the evidence is unclear. In the end, it’s a matter of balancing the low risk of these side effects with the potential benefit of lower risk of heart disease, stroke, and death. Have an open conversation with your doctor to consider your personal benefits and risks.
    Remember the other stuff. These new guidelines are quick to remind us that there is more to lowering cardiovascular risk than just taking a statin. We need to remain focused on living healthy as well—eating right, getting exercise, not smoking, and maintaining a healthy weight.

Other guidelines released this week—assessing cardiovascular risk, lifestyle management to reduce cardiovascular risk, and management of overweight and obesity in adults—can help us do this.

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