Take charge of your cholesterol levels by getting the latest on what medicines might be needed and how some changes in lifestyle can help make a difference.

1. Down with Cholesterol!
Prevent Heart Disease
Andrew D. Beamer, MD, FACC
Chairman, Department of Cardiology
Summit Medical Group

2. Down with Disease
• How big is this problem?
• Can we really prevent heart disease?
• The diet advice seems to change all the time…
• How can I know if I need to take medication?
• Do the medications really work?
• I’d rather take something natural…

4. Heart Disease: 25% of deaths
• 500,000 first MIs/yr
• 200,000 sudden death
• >50% of all Americans
have at least one
risk factor

5. The Enemy: Cholesterol Plaque
• Slowly builds up over
years to decades
• A complex “pimple” of
cholesterol-laden cells
under a cap
• Unstable plaque “pops”
causing formation of
a clot in minutes
• Starves heart muscle
downstream

6. How do we prevent these deaths?

7. The “Causes”
• Family History, Age,
Gender
• Smoking
• Diet
• Lack of Exercise
• Obesity
• Hypertension
• Diabetes
• “Cholesterol”

8. Smoking

9. Diet: World of Confusion?
“Each year patients are
bombarded with the
publication of new miracle diet
books that claim to … effect
weight loss and reduce disease
risks.”

10. Diet Advice has been
Remarkably Constant
• Fruits, vegetables
• Whole grain, nuts & legumes
• Protein from plants
• Minimal red meat
• Avoid saturated fats
• Use unsaturated fats

11. But What About Eggs?
• High in cholesterol,
low in fat
• One egg per day will
raise your cholesterol
by about 5 mg/dL

12. They Said to Use Coconut Oil
• Very high in
saturated fat
• Raises Cholesterol
• Palm oil is even
worse: lowers HDL

13. Fats and Oils
“Unsaturated” Fats—
Good Oils
• Usually liquid at room temp
• Canola
• Sunflower
• Corn
• Olive (EV*)
• Peanut
“Saturated” Fats—
Bad Oils
• Usually solid at room temp
• Animal fat
• Coconut
• Palm
• Trans-fats: partially
hydrogenated oils
Substitute good fats for bad fats!

14. Diet Specifics
• Berries & colorful vegetables,
• But NOT antioxidant supplements
• Nuts & Peanuts
• Green Leafy Vegetables
• Soluble fiber

15. But What About Red Wine?

17. Exercise: Just Do It
• You don’t need
to be an athlete
• 3-4 times/week
• 150 minutes/week
1.00
0.70
0.75
0.55
0.50
1.00
0.80
0.65
0.50
0.58
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
1.10
1 2 3 4 5
Relative
Risk
Walking
Any Physical Exercise

18. Obesity
1.0 1.0
1.4
3.1
4.6
5.8
0.0
1.0
2.0
3.0
4.0
5.0
6.0
19.0-21.9 22.0-24.9 25.0-26.9 27.0-28.9 29.0-31.9 32
Body Mass Index (BMI)

19. I thought we were going to talk
about Cholesterol?!
• In the end, all plaque
is “caused” by damage
to the arteries by
cholesterol

20. Oil and Water Don’t Mix
• Cholesterol can’t
travel naked in the
bloodstream
• Travels in capsules
called “lipoproteins”
• These particles
interact with the walls
of the arteries

21. Good guys and bad guys
• High density
lipoprotein—HDL
• “Healthy”
• Low density
lipoprotein—LDL
• “Lousy”

22. It’s Hard to Change HDL Levels
• Some people don’t
have many “cops”
• If you don’t have
much crime (LDL) you
don’t need as many
cops (HDL)
• Get the LDL down as
low as possible

23. But is it the Vehicles or the Passengers?
• Usual test measures
amount of cholesterol,
not number of
transporting particles

24. But is it the Vehicles or the Passengers?
ProbabilityofEvent-freeSurvival
Years of Follow-up
Low LDL-C – High LDL-P
(n=282)
High LDL-C – High LDL-P
(n=1251)
High LDL-C – Low LDL-P
(n=284)
Low LDL-C – Low LDL-P
(n=1249)
ProbabilityofEvent-freeSurvival
Years of Follow-up
Low LDL-C – High LDL-P
(n=282)
High LDL-C – High LDL-P
(n=1251)
High LDL-C – Low LDL-P
(n=284)
Low LDL-C – Low LDL-P
(n=1249)
ProbabilityofEvent-freeSurvival
Years of Follow-up
Low LDL-C – High LDL-P
(n=282)
High LDL-C – High LDL-P
(n=1251)
High LDL-C – Low LDL-P
(n=284)
Low LDL-C – Low LDL-P
(n=1249)
ProbabilityofEvent-freeSurvival
Years of Follow-up
Low LDL-C – High LDL-P
(n=282)
High LDL-C – High LDL-P
(n=1251)
High LDL-C – Low LDL-P
(n=284)
Low LDL-C – Low LDL-P
(n=1249)
The Number of Particles (Vehicles) Best Determines Risk

25. Who Needs Drug Treatment?
• CV risk is reduced by statins by 35-50%
• Why not treat everybody?
• Not worth it in lowest risk groups
• Treat based on the estimated RISK

26. • The highest risk:
• Previous heart attack, vascular disease, or equivalent
• High risk:
• Diabetes
• Severe high cholesterol—LDL >190 or LDL-P > 2000
• Moderately high risk:
• >7.5%/10 years
• Moderate risk?
• >5.0%/10 years
• Guidelines omit any mention of “targets”
Who Needs Drug Treatment?

27. How do you determine risk?
• Risk calculators
• Advanced lipid testing
(particles, other markers)
• Individual factors
(extreme family history)
• Testing?

28. CAT Scan Calcium Scoring
Detects Early CAD
• Cholesterol plaque
calcifies and becomes
easily visible
• Amount of Calcium
can be measured
• Total cholesterol
burden proportional
to amount of calcium

29. Use a Risk Calculator or
Get a Calcium Score?

30. https://www.mesa-nhlbi.org/MESACHDRisk/MesaRiskScore/RiskScore.aspx

31. Statins
• Reduce cholesterol
production in liver
• Reduce LDL cholesterol
• Reduce plaque growth
• Stabilize plaque
• Prevent heart attacks

32. Statins: Side Effects
• Statin associated muscle
discomfort is a challenge
• A common complaint
• Hard to diagnose
• Can usually be managed
• Change in statin or dose
• Co-Q10, Vitamin D
• Intermittent dosing
Side effects generally occur
at the time the drugs are started and
are reversible
Reversible liver inflammation is uncommon
No cumulative side effects from long term use

33. Patients who have had muscle aches don’t always
have them when they try statins again
Symptoms on
Statin
Yes No
Symptomson
Placebo
Yes 10% 26%
No 43% 17%

34. Other Drug Treatments
• Reduce recycling and absorption of
cholesterol in small intestine
• Ezetimibe (Zetia)
• “Resins”: cholestyramine (Questran)
colesevelam (Welchol)
• Omega-3 “fish oil”
• Limited use in specific cases
• Niacin
• Fibrates

35. • Soluble fiber
• Psyllium (Metamucil)
• Oats (Bran)
• Beans
• Plant stanols & sterols
• Supplements: Cholest-Off
• Margarines: Promise, Benecol, Smart Balance
Other Treatments

36. New Drugs?
• PCSK9 inhibitors
• Injectable
• Effective
• Expensive
• More to come?

37. “My friend told me to take
Red Yeast Rice”
Is Red Yeast Rice Extract a Drug or a Supplement?
The answer is both. One of the most important
ingredients in RYRE is monacolin K. It's also known
as lovastatin, the active ingredient in the
prescription drug Mevacor.

40. We have the means to reduce this epidemic
• Heart disease is rampant
• It can be reduced by wise lifestyle choices
• High risk persons can be identified,
but there is more to be discovered
• Early heart disease can be identified
before it becomes manifest
• Drug treatment can reduce the risk within months
• More therapies are becoming available

41. Any Questions?