Dr. Lee was born in Shanghai, China, and received his college and medical training in the United States. He is fluent in English and three Chinese dialects. He graduated with chemistry departmental honors from Harvey Mudd College. He was appointed president of AOA society at UCLA School of Medicine. He underwent internal medicine residency and gastroenterology fellowship training at Cedars Sinai Medical Center.
Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.
The ATP III recommended goal of LDL cholesterol lowering is tailored to a person's
heart attack risk. The expert panel recommended that patients with a higher
risk of heart attacks should be more aggressively treated so as to achieve
lower LDL cholesterol levels than patients with lower risks of heart attacks.
For example, patients with prior heart attacks (these patients are at high
risk of having a repeat heart attack) should have an LDL cholesterol goal of
< 100 mg/dl, whereas healthy subjects with no prior heart attacks and no
other risk factors should have an LDL cholesterol goal of <160mg/dl. (For a
detailed explanation of very high risk, high risk, moderate high risk, moderate
risk, and low risk patients, please see below).
Even then (in 2001), some cardiologists and cholesterol experts believed that aggressively
lowering LDL cholesterol below 80 mg/dl further decreases atherosclerosis
and heart attack rates among high risk patients. But, in order to
achieve these lower LDL cholesterol levels, moderate to high doses of a statin
drug (or drug combinations) often will be necessary on a long-term basis in
addition to lifestyle changes (please see discussion above). The safety of moderate
to high doses of statins over several decades is unknown. Therefore, based
on scientific information available at that time, the ATP III LDL cholesterol
target level of < 100mg/dl for high risk patients represents a
compromise, balancing the benefits of LDL cholesterol-lowering against the
potential side effects of long term moderate to high dose statins.
What were the findings of the large controlled trials published after 2001?
Since the publication of ATP III in 2001, five large controlled
cholesterol-lowering trials have been published. Three of these trials showed
that aggressively lowering LDL cholesterol (below 70-80 mg/dl) further decreased
the risk of heart attacks and strokes without significant increases in side
effects during the study period (usually from 3-5 years). These trials are: 1)
Heart Protection Study (HPS); 2)Anglo-Scandinavian Cardiac Outcomes Trial-Lipid
Lowering Arm (ASCOT-LLA); and 3) Pravastatin or Atorvastatin Evaluation and
Infection (PROVE IT).
The HPS trial randomly assigned more than 20,000 adults (aged 40 to 80 years)
with high heart attack risks to receive either a placebo or simvastatin (Zocor)
40 mg daily. The study found that there was an approximate 25% reduction in
heart attacks and strokes in men and women treated with simvastatin. This
reduction occurred even among patients whose LDL cholesterol was lower than 100
mg/dl at base line (before treatment), suggesting that there was a further
benefit in lowering LDL cholesterol levels below the target levels recommended
by ATP III.
The ASCOT-LLA trial randomly assigned more than 10, 000 patients with high
blood pressure to receive either a placebo or atorvastatin (Lipitor) 10 mg/day.
These patients had not suffered prior heart attacks. The study was stopped after
3.3 years (sooner than planned) because there was a convincing reduction in
heart attacks and strokes (by approximately 25%-30%) among the atorvastatin
treated patients. The average LDL cholesterol level dropped 29%, from 132 mg/dl
to 90 mg/dl in the atorvastatin treated group.
The PROVE IT trial was designed to determine whether aggressively loweringe
LDL cholesterol with a high dose, potent, statin drugs would reduce heart
attacks more than standard doses of statins. The patients involved in this study
were very high risk, having acute coronary syndromes (ACS), and thus were often
in imminent danger of experiencing heart attacks. Four thousand of these
patients were randomly assignedized to receive either a high dose (80 mg/day) of
atorvastatin (Lipitor) or a standard dose (40 mg/day) of pravastatin
(Pravachol).
As expected, the average LDL cholesterol attained with high dose atorvastatin
was 62 mg/dl, much lower than achieved with standard dose pravastatin, which was
95 mg/dl. At the end of two years, the incidence of heart attacks, strokes, and
the need for coronary artery bypass surgery were lowered by 16% in the
atorvastatin group as compared with the paravastin group. The PROVE IT study
suggests that aggressive lowering of LDL cholesterol below 70 mg/dl further
reduces heart attacks and other major coronary events (such as the need for
coronary artery bypass surgery) in patients at very high risk of heart attacks.
Angina is chest pain that is due to an inadequate supply of oxygen to the heart muscle.
Angina can be caused by coronary artery disease or spasm of the coronary
arteries. EKG, exercise treadmill, stress echocardiography, stress thallium, and cardiac
catheterization are important tests used in the diagnosis of angina.
Cholesterol is naturally produced by the body, and is a building block for cell membranes and hormones. Low-density lipoprotein (LDL) cholesterol is the "bad" cholesterol, conversely, high-density lipoprotein (HDL) cholesterol is the "good" cholesterol. High cholesterol treatment includes lifestyle changes (diet and exercise), and medications such as statins, bile acid resins, and fibric acid derivatives.
Heart attack happens when a blood clot completely obstructs a coronary
artery supplying blood to the heart muscle. A heart attack can cause chest pain, heart failure, and electrical
instability of the heart.
Rhabdomyolysis is a rapid deterioration and destruction of skeletal muscle. Some of the causes of rhabdomyolysis include severe burns, muscle trauma, coma, seizures, electrolyte imbalance, medications (statins), viruses, bacteria. Treatment of rhabdomyolysis depends on the cause.
Peripheral vascular disease (PVD) refers to diseases of the blood vessels (arteries and veins) located outside the heart and brain. While there are many causes of peripheral vascular disease, doctors commonly use the term peripheral vascular disease to refer to peripheral artery disease (peripheral arterial disease, PAD), a condition that develops when the arteries that supply blood to the internal organs, arms, and legs become completely or partially blocked as a result of atherosclerosis. Peripheral artery disease symptoms include: intermittent claudication, rest pain, numbness in the extremities, and more. Treatment for peripheral artery disease include: lifestyle measures, medication, angioplasty, and surgery.
When a portion of the brain loses blood supply, through a blood clot or embolus, a transient ischemic attack (TIA, mini-stroke) may occur. If the symptoms do not resolve, a stroke most likely has occurred. Symptoms of TIA include: confusion, weakness, lethargy, and loss of function to one side of the body. Risk factors for TIA include vascular disease, smoking, high blood pressure, high cholesterol, and diabetes. Treatment depends upon the severity of the TIA, and whether it resolves.
Heart attacks are the major causes of unexpected, sudden death among men and women. A heart attack is also a significant cause of heart failure. Learn the risk factors for heart attack such as high blood pressure, diabetes, and other heart conditions. Lowering your risk factor, lifestyle changes, and in some cases medication are the most effective way of preventing a heart attack.
A heart attack is a layperson's term for a sudden blockage of a coronary artery. This photo essay inlcudes graphics, pictures, and illustrations of diseased heart tissue and the mechanisms that lead to coronary artery disease, and possible heart attack.
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