Heart Disease, Living Well with (cont.)

With regard to cholesterol, there are also studies now that are suggesting the lower the LDL or bad cholesterol levels, the better. The target for people with heart disease has been 100 milligrams per deciliter, a number that should be easy to remember.

A recent national expert panel from the National Institutes of Health (NIH) indicated that a target of 70 might be beneficial, but they labeled that an optional target, acknowledging that the evidence that we should go down that far is not yet definitive. These discussions in the medical community should not confuse the patient. There are far too many people who are not below the target level of 100, a level for which there is strong consensus. If a patient working with their doctor would like to be more aggressive and gamble that going to 70 would be even better, then there would be evidence to support them, even though the jury is not in yet.

"The benefits of increasing physical activity, even a regular routine, of walking, can pay remarkable benefits."

MODERATOR:
You've described the first two strategies. What are steps three through seven?

KRUMHOLZ:
In the next list of strategies I talk about:

  • Taking charge of your fitness
  • Taking charge of your weight
  • Taking charge of your blood sugar
  • Taking charge of your smoking (obviously for smokers only)
  • Taking charge of your medications
Each of these strategies has a potential to confer substantial benefits.

In talking about fitness, I explain how physical activity can have a powerful effect on reducing risk and at the same time, provide considerable benefits with regard to quality of life and functioning. I urge people to think about fitness and weight as if they were a pill; that is, if these strategies were a pill, they would be miracle pills because of their abundance of benefits and virtual absence of side effects. Of course, making changes in lifestyle, which is really what is being suggested by these two strategies, can be challenging, but I tried to convey how their lives can be changed for the better.

MODERATOR:
How do you define fitness?

KRUMHOLZ:
Let me say that in this strategy, I am not talking about training for the Olympics, but talking about increasing physical activity. The benefits of increasing physical activity, even a regular routine, of walking, can pay remarkable benefits. And, it seems that both the duration and intensity of exercise can be important. But, maybe even the word exercise can be off-putting to some people. This is really about moving, getting your heart beating, moving your muscles and getting into a routine and lifestyle where physical activity is part of every day. It does not need to be strenuous, but there seem to be clear evidence if it becomes part of your regular daily habit.

MODERATOR:
Walking the dog, dancing to the radio, taking that after-dinner stroll through the neighborhood with your partner -- just get active.

MODERATOR:
Can you explain the role of C-reactive protein (CRP) in heart disease? It has been reported that reducing the level of CRP is as important as reducing the level of cholesterol.

KRUMHOLZ:
Our understanding of heart disease has undergone remarkable change in the last 10 to 20 years. We now appreciate that inflammation plays an important role in heart disease. Inflammation is really the body's own defense system in this case, working against us and placing us at risk.

C-reactive protein is a substance in the blood that indicates whether there is inflammation in the body and has turned out to be a good predictor of the risk of heart disease.

Now people are asking the question, can you lower risk by lowering CRP (C-reactive protein)? Some studies are suggesting that statin drugs, which are used to lower LDL cholesterol, may be useful in quieting inflammation and reducing the risk of heart disease. To this point, we lack a definitive study that proves the effectiveness of that strategy.

There is a large randomized trial that is currently underway in which patients with normal cholesterol levels, but elevated C-reactive protein levels, are being randomized to a statin drug or placebo. That study may help us understand whether the treatment of an elevated C-reactive protein should become, one day, a key strategy for the treatment of heart disease. But, for right now, it is uncertain whether treatment of C-reactive protein in that way is beneficial.

"I have known many patients who were the healthiest they ever were in their lives after their surgery and once they recognized what they needed to do to stay healthy."

MEMBER QUESTION:
What do you think of supplements such as polycosanol to lower cholesterol? If the cholesterol is naturally high due to heredity, can the polycosanol be used along with a lower dose of statin (to reduce likelihood of dangerous side effects)? Also, what are your thoughts about the long-term efficacy of relying on statins?

KRUMHOLZ:
I believe strongly in sticking with the best scientific evidence. For now, the best approach to lowering cholesterol is with the statin medications at doses that are known to reduce LDL. The risks of adverse effects are small. I'm not suggesting there are no risks, but they are small. Rather than trying a strategy for which there's much less evidence, I strongly recommend people stick with what has been demonstrated in the medical literature.


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