DEAR DR. ROACH: My doctor recently suggested I start taking a statin. After reading some of the recent literature, it appears that statin therapy is more controversial than in the past. From my reading, 50 percent of heart attacks occur in folks with normal cholesterol levels. A re-evaluation of previous studies (such as Framingham) have shown all-cause mortality is better in folks with higher cholesterol. Since our bodies make over 80 percent of our cholesterol, it appears that those with higher levels might need those level for good health. And it seems many of the degenerative diseases of aging occur more frequently in those with lower cholesterol levels. Researchers are now questioning whether it is the chronic inflammation or the actual cholesterol (mainly LDL) that contribute to these health problems. — R.R.
ANSWER: There certainly are people who argue against statin use. Clearly, statins aren’t for everybody. Some of what you say is right, but some is wrong or misleading. Let me explain.
Current recommendations for healthy cholesterol levels are a total cholesterol of less than 200. Only 20 percent of heart attacks happen to people who are in this group. Of the group of people with heart attack and normal cholesterol, many have other risks, such as low HDL, a family history of heart problems or are smokers. The important message from this is not that low cholesterol is dangerous, it’s that there are multiple risk factors besides high cholesterol.
All-cause mortality across the population is strongly associated with high total and high LDL cholesterol. The exception is in frail elderly people, often those with other medical illnesses, where malnutrition (associated with low cholesterol) is a real problem. This may be why people with chronic or degenerative diseases have low cholesterol: It’s an effect of the disease, not a cause. For healthy adults of any age, the higher the cholesterol, the greater the risk of heart disease and all-cause mortality.
Chronic inflammation undoubtedly is a cause of development of coronary artery disease and heart attacks. People with chronic inflammatory diseases appear to be at higher risk for heart attack, even with normal cholesterol levels. On the other hand, even people with normal cholesterol levels have a reduced chance of developing a second heart attack by taking a statin. Also, people with high levels of an inflammatory marker, C-reactive protein, get benefit from statins even if they have no known heart disease.
The decision to take a statin is complex, and it should be based on all of a person’s risk, including nontraditional risk factors like chronic stress, and known risk factors that we physicians often fail to emphasize, like physical inactivity and poor diet. High cholesterol alone might not be reason enough to take a statin, and some people with normal cholesterol would benefit from statins. Only a comprehensive evaluation can answer whether a statin would be of benefit.
DEAR DR. ROACH: In the past few years, I’ve been experiencing “volatile blood pressure.” It will go from 71/38 to 280/90 in half an hour. It happens in all situations. I could be knitting and do a check, and it will be 200/68. The emergency and ambulance teams know me very well. I have had 24-hour urine tests and lots of bloodwork. Most of the time it is low, so how can I raise it up? I was on 25 milligrams of Cozaar (losartan), but it caused a real dive. Do you have any advice on how to control this? —P.D.
ANSWER: Volatile, or labile, blood pressure can have several causes. Although it is rare, a pheochromocytoma must be considered. It is a tumor that can intermittently secrete substances, like epinephrine, that raise the blood pressure. I am pretty sure the 24-hour urine test was to look for this. Blockages in the arteries to the kidneys sometimes cause spikes of blood pressure, as can some other uncommon causes.
If your doctor is convinced that there is no identifiable medical condition causing these high pressures, he or she may wish to give you treatment you can take at home when the pressure is very high, rather than sending you to the emergency room each time. There are several blood pressure regimens that are recommended for labile blood pressure, but all of them are limited by blood pressure getting too low.
In many people, despite no apparent symptoms of anxiety or depression, adding an antidepressant sometimes can eliminate the blood pressure spikes and improve your quality of life. It’s thought that there may be emotional issues that people are not consciously aware of. It may be worth a short trial (a few weeks) to see if this type of treatment can help stabilize the blood pressure.
