Primary prevention of heart disease is possible!

Statin can play a part, but lifestyle changes are the safer choice for heart disease prevention

I did not immediately think about heart disease and its prevention when I met Andy this week. Being 42 years old, he presented with vague symptoms of lethargy and difficulty in performing his physically demanding job at the airport (where he was also exposed to exhaust fumes.) He has 12 silver dental fillings, having loved sweets since early childhood. He also has a strong family history of premature heart disease, as his father died of a heart attack at the age of 46. He was extremely concerned about his health.

He estimated his energy levels to be 4 out of 10, but fluctuating, particularly after a meal, with a significant dip after lunch. Andy retires to bed around midnight but regularly wakes up between 3 – 4 am and cannot go back to sleep, and he does not feel fully refreshed in the morning.

Andy’s BMI was at the upper normal level at 24.5, blood pressure high at 135/85. Routine blood tests were unremarkable with Cholesterol at 5.1, HDL (the good guy) normal at 1.5, LDL the bad guy normal at 2.4, but triglyceride (lousy cholesterol) very high at 2.4; fasting blood sugar is pre-diabetic at 6.4, and HbA1C (reflecting the cumulative blood sugar control over the last 3 months) was at the upper normal range of 38.

Although Andy‘s complaint was related to energy levels, I suggested our priority should be to investigate his cardiovascular risk, despite him having normal cholesterol, including the bad guy.

One cause for lethargy AND cardiovascular risk?

Andy agreed with the clinical decision, and in fact, he reflected that he had been extremely concerned as he was approaching his father’s age when he died. Andy felt reassured as I advised him that working on his cardiovascular risk may positively impact his energy problem, as the two conditions may have originated from a common underlying cause.

Andy’s more specialised test results came back and confirmed a very high level of inflammation and oxidative stress (rusting). This is enough to damage his mitochondria and compromise his energy levels, and at the same time inflaming his arteries, oxidising LDL, the bad guy, and set the scene for vascular disease.

The risk of heart disease increases with age in both males and females, particularly females after menopause; the risk is higher in ladies with a history of gestational (pregnancy) diabetes or those who gave birth to a large baby; also in women diagnosed with polycystic ovary syndrome (PCOS) and those who have early menopause, before the age of 40. In men, erectile dysfunction is the most common and strong risk factor for vascular disease. Again, patients diagnosed with sleep apnoea or non-alcoholic fatty liver disease are particularly at high risk of vascular disease.

What risk factors should be on your radar?

Going through the assessment, I found that Andy satisfied the diagnostic criteria for metabolic syndrome. These include excess fat around the middle (his waist was 42 inches), pre-hypertensive blood pressure at 135/85, a pre-diabetic fasting blood sugar at 6.4, a very high triglyceride (lousy fat) at 2.4. However, the cholesterol family, including the good guy and the bad guy, were normal. We diagnose metabolic syndrome when 3 out of 5 risk factors are positive. However, studies have stressed even one positive factor increases your risk of cardiovascular disease.

Doctors strive to diagnose metabolic syndrome early because it is a great opportunity to prevent vascular disease. Controlling various risk factors such as high blood pressure and high blood sugar at an early stage stop progression of the disease and prevent complications such as diabetes and vascular disease. These include heart disease, stroke, chronic kidney disease, and peripheral vascular disease, which often compromise blood supply and result in limb amputation.

The American Heart Association reported that 23% of adults currently have metabolic syndrome. Reaching these people early and helping them to reduce their risk factors will prevent those serious complications.

Vascular risk calculator

You cannot stay in the dark about this serious health issue. Being proactive and visiting an online vascular risk calculator enables you to access your risk and take early action to resolve it. Framingham was the earliest tool found to calculate your chance of having a heart attack or stroke in the next 10 years. A risk of 10% or more is severe and should prompt you to take immediate action.

Beware, these risk calculators are not supposed to replace doctors but should prompt you to seek medical help early. Individual calculators were produced from local population data; hence it makes sense to stick to your local risk calculator. For example, NICE recommend the QRISK2 risk calculator in the UK.

Risk calculators are helpful but are not adequately implemented in clinical practice; they are of limited value in assessing people over the age of 79 and those under 40 due to a lack of data to predict the risk. Most of these calculators do not assess triglyceride, a serious risk factor of vascular disease. Risk calculators support the clinical decisions and can facilitate communication of the decision to the patient and their family, and may motivate the patient to take action.

On the other hand, these tools can help people to avoid over-treatment, reduce cost and prevent medications side effects.

At this point, Andy’s eyes lit, and he hurried to ask another question about the treatment of those discovered to have a high vascular risk?

I offered that positive cases are usually offered adequate treatment to control their blood pressure and blood sugar plus statin, together with low-dose aspirin to prevent thrombosis, which can lead to heart attack and stroke.

Statins are used to lower cholesterol, specifically LDL (the bad guy); it is also claimed that statins draw cholesterol out of the arterial plaques and stabilise them. Some studies reported that statins are helpful in patients who find it hard to stick to a healthy diet. But many studies have found the benefit of taking a statin to be exaggerated, and worse, their side effects understated.

A few doctors continue to recommend healthier lifestyles, such as weight loss and increasing physical activity, but this was inconsistent as 50% of smokers, in a study, were not advised to quit.

Andy felt overwhelmed with the information about the risk calculators, the indication for a statin and asked if there were a natural, straightforward approach to his problem.

I mentioned that men in the top 1% of incomes live 14.6 years longer than those in the bottom 1%, illustrating lifestyles’ impact on health.

I emphasised my belief that the most important risk factor to correct is insulin resistance, triggered mainly by belly fat. Insulin resistance makes it harder for the body cells to process sugar, whilst improving insulin sensitivity positively impacts all other vascular risk factors.

The history of fluctuating energy levels, particularly after meals, afternoon energy dip and waking up consistently between 3 to 4 am without going back to sleep in Andy’s history suggests a significant sugar problem.

I also explained the three-component vascular atherosclerosis process that starts by low-grade inflammation, often triggered by belly fat; oxidative stress (rusting), that damage LDL (the bad guy); initiating the plaque formation, the hallmark of vascular disease.

At this point, Andy started to see the connection between lethargy and lack of energy, the primary symptoms with which he presented, and the development of vascular disease.

I explained, Andy’s diet was high in sugar and processed carbohydrate most of his life, exposing him to a high level of oxidative stress (rusting). He was then exposed to more oxidants in aeroplanes fumes whilst pursuing his job in the airport for many years. This is enough to damage his mitochondria (energy plants) to cause lethargy and low energy levels. And at the same time initiated Andy’s vascular disease and was probably the culprit of Andy’s father premature heart disease and early death. I informed Andy the likely conclusion is that Andy has inherited a flawed antioxidant barrier system that makes him highly susceptible to oxidative stress (rusting) damage.

The natural way versus statin

Andy was worried and said he did not want to go on statin pills for life, but I reassured him that we could solve the problem by natural means.

You can lower your cholesterol, including the bad guy, by eating a plant-based high fibre diet of fruits and vegetables, beans, and whole grains; healthy fat of avocado, fish and olive oil, nuts and seeds. You can also raise your HDL (the good guy) by increasing physical activity (a brisk walk for 30 minutes five times a week), quitting smoking, avoiding saturated fat and losing 10% of your non-ideal bodyweight. In this way, arterial plaque can be stabilised and vascular risk significantly reduced.

NICE does recommend that most patients try lifestyle modifications before they think about taking statins. After a sufficient period of healthier living, NICE offers another assessment to monitor the vascular risk. With insufficient improvement, the choice would be between continuing to change your lifestyle plus taking a statin or continuing with lifestyle changes without statin.

Being at risk doesn’t necessarily mean you should take a statin. Some people are reluctant to take drugs for life and worry about the undesirable side effects. Statins can increase the risk of type 2 diabetes, memory loss, cataract, and liver, muscle and kidney damage.

According to the Mayo Clinic, these side-effects occur more often in females, those with type 1 or type 2 diabetes, those who take multiple medications to lower cholesterol, those who have a smaller body frame, liver or kidney disease, or consume too much alcohol.

The first step in reducing your risk of cardiovascular disease is lifestyle modification that includes stopping smoking, eating a healthy diet, enjoying adequate sleep and good physical activity, having a healthy weight, and reducing your alcohol intake

So, you can see my friends that online self-assessment is helpful to learn about your vascular risk, statin may have a part to play for some, a healthy lifestyle once again presents a safe, straightforward solution for so many health issues, including, in Andy’s case, both his lethargy and his cardiovascular risk. Please do share your thoughts and any questions on this subject, and please do subscribe to the newsletter so that you don’t miss further vital information. Thank you!