Yes. If you have a healthy balanced diet, you do not need additional vitamin E. Any extra vitamin E you take is a waste of money and does not reduce your risk of getting coronary heart
Plaque begins to encroach into
Plaque begins to encroach into
disease. But you should discuss this and any other changes with your doctor.
IS ATHEROMA THE SAME AS CHOLESTEROL?
The main constituent of atheroma is cholesterol. Plaques of cholesterol get deposited in the inside of arteries from a very early age. The arteries that are mainly affected are those in the brain, the neck, the heart, the aorta, and the leg.
Unless the cholesterol level and in particular, the LDL cholesterol, is lowered, more fatty material is deposited on top of the fatty plaque. This may obstruct the artery, resulting in angina. Plaques may become unstable. The surface may crack (rupture) and a blood clot form on top of the plaque, causing unstable angina or a heart attack and death.
IS CHOLESTEROL MORE LIKELY TO BE DEPOSITED IN ARTERIES IN PEOPLE WHO HAVE OTHER RISK FACTORS FOR CORONARY HEART DISEASE?
Yes. A high cholesterol level is even more dangerous in people who have any other risk factor. So a person with high cholesterol and any one or more of the following risk factors:
• family history of heart problems at a young age
• kidney problems is very much more likely to get blocked arteries and have a higher risk of heart attack and stroke than someone who only has high cholesterol. The more risk factors a person has, the greater the chances of that person developing coronary heart disease and its consequences.
People with high cholesterol and any one of these cardiovascular risk factors will probably need medications to lower their cholesterol.
WHAT CAN BE DONE TO REDUCE THE CHOLESTEROL LEVEL?
Eat less fat, particularly saturated fat. Having a very low fat diet and reducing alcohol can reduce the cholesterol and LDL level by approximately 10%. Alcohol does not contain cholesterol, but it interferes with the way the liver metabolizes it. If the cholesterol remains high despite these measures and the patient is doing their best, then medication may be necessary.
WHAT MEDICATION IS USED TO LOWER CHOLESTEROL?
The most commonly used and the most effective drugs are statins (they all end in "-statin"). There are five different types that all act in a similar way, although some are more powerful than others. They block the production of cholesterol in the liver by blocking an enzyme used in its production.
Simvastatin can now be bought over the counter in the UK. Statins are very helpful and effective drugs and have made a big difference to the way we prevent and treat people with coronary heart disease.
HOW EFFECTIVE ARE STATINS?
• heart attacks
• death from heart attacks
Statins are now available combined with another medication called ezetimibe. Ezetimibe lowers cholesterol by reducing its absorption from the gut into the blood. This combination is even more effective than a statin alone but is more expensive and is used in people whose cholesterol remains high despite a big dose of statin. Combination drugs are more convenient for patients.
PRIMARY PREVENTION - TRYING TO PREVENT ARTERIAL BLOCKAGE IN SOMEONE WHO HAS NORMAL ARTERIES
A statin is used if a person is at an increased risk of getting vascular disease. This is estimated using special charts. These charts provide a very rough estimate of the probability that a person will have a heart attack or stroke within 10 years based on gender, age, blood pressure, cholesterol level, and whether or not they are a smoker and/or diabetic. A person's risk is lumped into risks of less than 15%, 15-30%, and more than 30% depending on which color section of the graph they fall into.
The charts are by no means perfect because they do not take into account other important risk factors (e.g., weight, level of activity, "stress levels," family history, and the number of cigarettes smoked). Also, the estimate derived from the table is very approximate and slightly misleading. A person who is estimated to have a 15% risk of having a stroke or a heart attack would be advised and prescribed a statin, but a person with only a slightly smaller risk of 14% may not be given a statin. The charts are only guidelines, not law. As in most areas of medicine, doctors use guidelines as guidelines and treat the patient in front ofthem because each patient is different.
Restricting statins to people estimated to have a risk of having a stroke or heart attack within 10 years, reduces the cost of treatment and targets those at higher risk. Using a risk cut-off value of 15% (in some countries the cut-off level used is 10%) means that people who may benefit from a statin may not be getting treatment that might reduce their risk of coronary heart disease.
In many countries, statins are available over the counter. It is important that they are taken only when there is a good reason and to remember that they do, occasionally, like all tablets, have side effects.
WHAT ABOUT THE USE OF STATINS IN PEOPLE WHO HAVE CORONARY HEART DISEASE (SECONDARY PREVENTION)?
• People with coronary heart disease - those who have had coronary artery surgery, angioplasty, or a heart attack, and those with angina should be on a statin.
• People with blockages in their leg (peripheral vascular disease) neck, or brain arteries, and those who have had a stroke or a "mini" stroke (transient ischaemic attack - cerebrovascular disease) should be taking a statin every day unless they cannot tolerate them, which is very rare.
Importantly, these patients should take a statin even if their cholesterol level is normal. The reason is that statins, whatever the cholesterol level, reduce the inflammation in arteries, and make the fat deposits in the arteries less liable to crack and cause trouble, for example, heart attacks and stroke.
People with furring up in any artery should be on a statin.
WHAT ABOUT THE ELDERLY?
Statins should be used in the elderly although there is little information about their safety or benefits in people aged over 70 years. This applies to lots of other treatments in all areas of medicine because most drug trials exclude the elderly. The risks of drugs interacting with another, increase as the number of drugs taken, increases. Because elderly people are likely to have more than one medical condition, they are likely to be taking more than one drug. Therefore, they may not want to take another drug for a condition that does not worry them unduly, and if they do, they may get a side effect.
Some doctors may feel less inclined to prescribe a statin to elderly patients. Even though a 90-year-old is much more likely to have a heart attack or stroke than a 60-year-old, some 90-year-olds feel that they have managed to reach the age of 90 without statins, which may have side effects and make them feel unwell for the last part of their life, without making a significant difference to their lifespan. In these cases (as in all cases), the patient's views, assuming they are able to understand, should be taken into account.
SHOULD EVERYONE BE ON A STATIN?
No. The most sensible thing would be to discuss it with your doctor. Find out whether you should be on one or not depending on your risk factors (primary prevention) or whether you should be on one irrespective ofyour riskfactorsbecause ofyour medical history. They should not, like most other drugs, be used during pregnancy.
WHO SHOULD NOT BE ON A STATIN?
• People with liver disease
• People who drink a lot of alcohol
• People who cannot tolerate them
WHAT ARE THE SIDE EFFECTS OF STATINS?
Side effects are unusual. They include disturbance of liver function, painful muscles, gas, an upset tummy, and occasionally a rash. Very rarely, around 1 person in 100,000 may get a serious inflammation of the muscles in the legs and arms (rhabdomyol-ysis). This would get better over time when the drug is stopped.
How Do You Know if a Person Has Side Effects?
A blood test, to check the liver function, the cholesterol levels, and the muscle enzymes, is taken 6-8 weeks after starting the statin and, perhaps, every six months thereafter.
WHAT HAPPENS IF THE LIVER FUNCTION TESTS ARE ABNORMAL AFTER STARTING THE STATIN?
If the liver function tests are more than three times the upper limit of normal, and stay at this level, then the statin should be stopped. Sometimes, a different statin can be tried, but this may cause the same problem. The different statin should not be started until the liver function tests return to normal, which they usually do.
WHAT HAPPENS IF THE CHOLESTEROL LEVEL REMAINS HIGH AFTER STARTING THE STATIN?
The dose can be increased, but the patient will need another blood test to make sure the bigger dose has not upset the liver blood test. Another drug, called ezetimibe, can be added in.
DOES THE CHOLESTEROL DECREASE AS THE DOSE OF STATIN IS INCREASED?
Yes, but only slightly. Doubling the dose of statin does not further halve the cholesterol level. Doubling the statin dose results in a further 10% reduction in cholesterol.
WHAT HAPPENS IF A PATIENT WITH HIGH CHOLESTEROL CANNOT TOLERATE THE STATIN?
Ezetimibe is a relatively new drug that blocks the absorption of cholesterol in the gut. It is usually used together with a statin and lowers the cholesterol level by a further 15%. The combination of a high dose of statin and ezetimibe can lower the LDL cholesterol by as much as 50%. It can affect the liver, and the side effects are diarrhea, nausea, headache, tummy ache, and occasionally a rash. On its own, it is not as effective as statins. It is not given with fibrates.
Fibrates are a group of drugs that lower the triglyceride level. They have little effect on the LDL cholesterol. They can also be used with statins, but the risk of muscle inflammation (myositis) increases. They can also cause tummy upsets, kidney problems, and impotence.
Nicotinic acid has a moderate lowering effect on LDL cholesterol. It is not used very commonly. It is used with a statin to treat patients who have a high triglyceride level and a low HDL cholesterol level. It can increase the protective "good" HDL cholesterol by 30%. The side effects are flushing and liver problems.
Bile acid sequestrants lower the LDL cholesterol by 15% and increase the HDL cholesterol level. They are rarely used nowadays because patients find the side effects of constipation, bloating, nausea, and flatulence intolerable.
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