What Cholesterol Level To Start Statin

Can You Have Grapefruit Juice When Taking A Statin

Grapefruit juice interferes with how your body processes the statin drug. This can cause the statin to hang around your body at higher levels and for longer periods than necessary. This study showed that drinking 10 ounces of 100% grapefruit juice every day did raise atorvastatin levels, but it did not cause muscle or liver side effects.

Secondary Prevention: How Low Should We Go

In patients with overt CVD, the guidelines state an optional goal LDL of 70 mg%. This recommendation is based on several recently published trials that examined the effect of aggressive LDL lowering therapy in high risk populations of patients . In the PROVE-IT TIMI 22 trial, 4,162 patients 10 days after an acute coronary syndrome were randomized to standard 40 mg pravastatin treatment or high dose/aggressive 80 mg atorvastatin treatment . Patients were followed for 18 to 36 months and achieved an average LDL cholesterol level of 62 mg% in the atorvastatin group and 95 mg% in the pravastatin group. In the aggressive therapy group versus the control group, a significant 16% reduction in the primary end point was noted. 18% of the 1,600 patients in each treatment arm suffered from diabetes and showed similar risk reduction to that of the general cohort. A post hoc analysis of the PROVE-IT TIMI 22 trial data revealed a reduction not only in LDL cholesterol but also in CRP levels. This reduction in CRP was significantly associated with a reduction in cardiovascular events irrespective of the associated LDL reduction .

People With Familial Hypercholesterolemia

This inherited condition occurs in 1 in 250 adults and causes cholesterol levels to be extremely high, even in childhood. Without a statin, people with familial hypercholesterolemia may have a heart attack in their 20s or 30s.

Other people may benefit from taking a statin, depending on age, sex, race, blood pressure, smoking, and other medical conditions. These factors and others are used to estimate your risk of developing cardiovascular disease. Statins are more likely to help people with high risk rather than low risk.

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What Happens When I Take A Statin

You should have a blood test before starting treatment. This checks the level of cholesterol. It also checks if your liver is working properly. After starting treatment you should have a blood test within 1-3 months and again at 12 months. The blood test is to check that the liver has not been affected by the medication. The blood may also be checked to measure the cholesterol level to see how well the statin is working.

Estimation Of Ldl Particles Via Cholesterol Content

Chemical measures of lipid concentration have long been the most-used clinical measurement, not because they have the best correlation with individual outcome, but because these lab methods are less expensive and more widely available.

The lipid profile does not measure LDL particles. It only estimates them using the Friedewald equationby subtracting the amount of cholesterol associated with other particles, such as HDL and VLDL, assuming a prolonged fasting state, etc.:

L T

where H is HDL cholesterol, L is LDL cholesterol, C is total cholesterol, T are triglycerides, and k is 0.20 if the quantities are measured in mg/dl and 0.45 if in mmol/l.

There are limitations to this method, most notably that samples must be obtained after a 12 to 14 h fast and that LDL-C cannot be calculated if plasma triglyceride is > 4.52 mmol/L . Even at triglyceride levels 2.5 to 4.5 mmol/L, this formula is considered inaccurate. If both total cholesterol and triglyceride levels are elevated then a modified formula, with quantities in mg/dl, may be used

L T

This formula provides an approximation with fair accuracy for most people, assuming the blood was drawn after fasting for about 14 hours or longer, but does not reveal the actual LDL particle concentration because the percentage of fat molecules within the LDL particles which are cholesterol varies, as much as 8:1 variation.

Normal ranges

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Role In The Innate Immune System

LDL interfere with the quorum sensing system that upregulates genes required for invasive Staphylococcus aureus infection. The mechanism of antagonism entails binding apolipoprotein B to a S. aureusautoinducer pheromone, preventing signaling through its receptor. Mice deficient in apolipoprotein B are more susceptible to invasive bacterial infection.

Agreement Between Aha/acc And Esc/eas Guidelines

There is agreement that elevated LDL is the major atherogenic lipoprotein and that LDL-C is the primary target of treatment. Likewise, both guidelines agree that the intensity of LDL-C lowering therapy should depend on absolute risk to patients. In other words, patients who have highest risk should receive most intensive cholesterol reduction. Both guidelines emphasize therapeutic lifestyle intervention as the foundation of risk reduction, both for elevated cholesterol and for other risk factors. The highest risk patients are those with atherosclerotic disease and are potential candidates for combined drug therapy for cholesterol-lowering. For primary prevention, the intensity of treatment depends on absolute risk as determined by population-based algorithms. For drug therapy, statins are first-line treatment, but in highest risk patients, consideration can be given to adding non-statin drugs . Beyond population-based algorithms for primary prevention, measurement of other dyslipidemia markers or other higher risk conditions can be used as risk- enhancing factors to modify intensity of lipid-lowering therapy.

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Can Statins Increase My Risk For Memory Loss Or Dementia

Memory and cognitive symptoms from statin use are very uncommon, and it is unclear if statins are really the culprit. When symptoms have been reported, theyre typically not severe and usually resolve when the statin dosage is adjusted or the medication is switched.Affected patients have reported feeling unfocused or fuzzy in their thinking, but these experiences are rare. Concerns about long-term cognitive problems and memory loss due to use of statins have not been proven. On the contrary, most recent data actually point to potential prevention of dementia due to statin use.These data are logical because one of the major causes of dementia is atherosclerosis, which is hardening of the arteries in the brain. There is strong evidence that statins protect against atherosclerosis. Its one of the invisible benefits of taking a statin medication.Also, keep in mind that increasingly high cholesterol and memory problems both are common symptoms of aging. Sometimes its difficult to disentangle these two, and thats why statin use and memory problems may seem related at times.If youre concerned about statins and memory loss, dont stop taking your medication without consulting your doctor. There may be other reasons for your memory symptoms, or alternate treatments for your high cholesterol can be considered.

American College Of Cardiology/american Heart Association Guidelines On Management Of Lipids 2013

The ACC/AHA brought out the updated guidelines, in November 2013. The guidelines have emphasized the adoption of a healthy lifestyle as the foundation of cardiovascular health. The guidelines have identified four risk groups where lipid lowering measures have been found to be most effective. . Statins due to the overwhelming evidence have been recommended for treatment of elevated cholesterol. It has done away with titrating statin dose to achieve a desired LDL-C level. The dosing of statin has been fixed as high intensity and moderate intensity . For primary prevention in patients considered at low risk the guidelines recommend a discussion between the clinician and patient before initiating statin therapy. The guidelines recommend the use of Pooled Cohort Equation for assessing the 10 years risk of ASCVD. The Pooled Cohort Equations have been derived from cohorts of African Americans and White Americans who were part of five large NHLBI-sponsored observational studies on assessing cardiovascular health. Monitoring lipid profile is also not recommended as routine except to ensure adherence to therapy.

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While The Guidelines Dont Recommend A Specific Target For Treatment They Do Suggest Additional Therapy In High

CHICAGO, IL New cholesterol guidelines from the American College of Cardiology and American Heart Association break ground by recommending ezetimibe and/or PCSK9 inhibition in selective high-risk patients and proposing noninvasive coronary artery calcium screening to help make decisions about patients who fall into the gray zone for treatment.

Presented today at the AHA 2018 Scientific Sessions, the new guidelines121 pages in length and 18 months in the makinginclude 72 recommendations, including 29 that are class I. In general, the ACC/AHA guidelines include a broad spectrum of support from numerous societies and recommend a heart-healthy lifestyle across the entire life span.

Richard Kovacs, MD , vice president of the ACC, said the latest guidelines will help transform cardiovascular care and improve heart health. High cholesterol is both often preventable and eminently treatable, but as we move into an era where care is personalized, how we treat individual patients can vary, said Kovacs. This guideline will give clinicians the tools that we need to have those conversations with patients about the most appropriate treatment for their high cholesterol.

While there is no target for ideal LDL cholesterol levels in the general population, the guideline recognizes, in principle, that lower is better. Ivor Benjamin

Whats New in the Secondary Prevention Setting?

In other words, the most intensive LDL-lowering is reserved for those at the highest risk. Neil Stone

What Foods Should Be Avoided When Taking Statins

A: While taking atorvastatin , avoid high-fat and high-cholesterol foods as part of your overall treatment. You should avoid large quantities of grapefruit or grapefruit juice, which can increase the risk of serious side effects. Also, avoid excess alcohol use, as this may cause serious liver problems.

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Statin Use In Adults Aged 40 To 75 Years

Nineteen RCTs evaluated the effects of statins vs. placebo or no statins in adults aged 40 to 75 years without known CVD. Most of the trials, including the recently published HOPE-3 trial,8 enrolled participants based on an elevated LDL-C level, a diabetes diagnosis, or at least 1 CVD risk factor. Use of low- or moderate-dose statins was associated with a reduced risk of all-cause mortality , cardiovascular mortality , ischemic stroke , heart attack , and a composite cardiovascular outcome .6

Among the study populations, the proportion of CVD events prevented was similar across age, sex, race/ethnicity, lipid level, and other risk factor categories.6 Among trials that stratified participants according to a baseline global cardiovascular risk score, similar relative risk estimates were observed among those classified at a higher vs. lower CVD event risk.10,23

In the absence of other risk factors, adults with an LDL-C level greater than 190 mg/dL may still fall below the risk threshold for statin use for CVD prevention. As noted previously, these persons were generally excluded from the prevention trials evaluating the effects of statin use on health outcomes, because expert opinion strongly favors intervention for these individuals. It is possible that the relative risk reduction in this group is higher than in adults with a lower LDL-C level and that the absolute benefit is greater than would be predicted from a risk calculator.24

Will Statins Increase My Risk For Diabetes Or Complicate My Existing Diabetes

This risk is true to some extent, but its wildly exaggerated.In fact, there are good data to show that people who have problems with their blood sugar or who have diabetes benefit most from statins. Even though their blood sugar may go up slightly, the added risk is significantly offset by the reduction in heart disease risk that a statin can provide.If youre already at risk for developing Type 2 diabetes, or if you have prediabetes, you may monitor your blood glucose more closely after starting a statin. But exercise and weight loss have been shown to lower the risk of developing diabetes in those with borderline blood glucose levels, regardless of statin use.

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Patient Population Under Consideration

These recommendations apply to adults 40 years and older without a history of CVD who do not have current signs and symptoms of CVD . Some individuals in this group may have undetected, asymptomatic atherosclerotic changes for the purposes of this recommendation statement, the USPSTF considers these persons to be candidates for primary prevention interventions. These recommendations do not apply to adults with a low-density lipoprotein cholesterol level greater than 190 mg/dL or known familial hypercholesterolemia these persons are considered to have very high cholesterol levels and may require statin use.

Classes Of Recommendation Levels Of Evidence

The guidelines award classes of recommendations, signifying the certainty of benefit compared with the estimated risk and the strength of the recommendation.

• Class I benefit greatly exceeds risk treatment is recommended

• Class IIa benefit exceeds risk treatment is reasonable

• Class IIb benefit equals or exceeds risk treatment might be reasonable

• Class III: No benefit benefit equals risk treatment is not recommended

• Class III: Harm risk exceeds benefit.

The guidelines also award levels of evidence to their recommendations:

• Level Ahigh-quality evidence

• Level B-Rmoderate-quality evidence from randomized controlled trials

• Level B-NRmoderate quality evidence from nonrandomized trials

• Level C-LDlimited data

• Level C-EOexpert opinion.

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Who Should Take A Statin

Your doctor will advise if you should take a statin. A statin is usually advised if:

• You have a high cholesterol level .
• You have an atheroma-related disease. This is a cardiovascular disease such as angina or peripheral arterial disease, or you have had a heart attack , stroke or transient ischaemic attack . A statin helps to reduce the risk of these conditions getting worse or, it can delay the disease becoming worse.
• You have a high increased risk of developing an atheroma-related disease. For example, if you have diabetes, or other risk factors. Risk is measured as a percentage. Risk is considered to be high when your score is 10% or more . See the separate leaflet called Cardiovascular Health Risk Assessment.

Note: a statin is just one factor in reducing your risk of developing cardiovascular diseases. See the separate leaflet called Cardiovascular Disease .

What About Healthy People With Moderately Elevated Cholesterol Levels

What about healthy people who dont fit into the above categories? The guidelines provide clear guidance, but things do get a bit more nuanced. Here, there really needs to be a discussion between the patient and their doctor.

Whether to start a statin or not depends on whether there are other cardiovascular risk factors, such as smoking, high blood pressure, or diabetes, and the actual LDL-C level. A family history of premature atherosclerotic cardiovascular disease would be another factor to consider, as might South Asian ethnicity or premature menopause . Other blood test abnormalities, such as elevated triglycerides or elevated high-sensitivity C-reactive protein levels , might also push towards starting someone on a statin. Another recommendation in the new guidelines is for potential use of coronary artery calcium scans to decide whether or not to initiate statin therapy in select cases where the decision based on clinical risk factors is unclear. Patient preferences and cost are other potential issues to weigh. Online risk calculators may help.

Bottom line: If you are one of the large number of people who fall into this category, talk to your doctor about whether you should be on medications to lower your cholesterol, or whether lifestyle changes are enough.

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People With Cardiovascular Disease Caused By Atherosclerosis

This includes people who have had:

• A heart attack or other problems from blockage of the coronary arteries of the heart

• A stroke or mini-stroke or blockage of carotid arteries in the neck

• Leg pain caused by blockage of peripheral arteries

• Aneurysm or bulging of the abdominal aorta

The goal of using statins is to prevent further problems, like a second heart attack.

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The health body says if you accidentally take too many statin tablets, more than your usual daily dose, contact a doctor or pharmacist for advice or call NHS 111. It says statins come as tablets that are taken once a day, and for some types of statin it does not matter what time of day you take it, as long as you stick to the same time. High cholesterol is said to account for seven percent of deaths in England, according to the UK Government.

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Do You Have High Cholesterol

Cholesterol is a waxy substance that your body uses to make cells, certain hormones, and vitamin D. High cholesterol can lead to the build-up of fatty sludge in your arteries in a process called atherosclerosis.

Atherosclerosis can cause serious health problems when it affects major blood vessels. These health problems are referred to as cardiovascular disease.

Depending on where the atherosclerosis is, the symptoms are different:

• Atherosclerosis of the arteries that nourish the heart can cause heart attacks, heart failure, chest pain , or abnormal heart rhythms.

• Atherosclerosis of the arteries in the neck can cause stroke, mini-stroke , or vascular dementia.

• Atherosclerosis of the arteries in the legs can cause pain, slow-healing wounds, skin ulcers, or dead tissue .

• Atherosclerosis of the arteries that feed the kidneys can cause kidney failure or high blood pressure.

• Atherosclerosis of the aorta, the largest artery in the abdomen, can cause a ruptured aorta with life-threatening internal bleeding.

Statins And Clinical Trial Evidence

Statins were discovered in the 1970s by Endo of Japan . These drugs lower cholesterol by inhibiting cholesterol synthesis in the liver. They block HMG CoA reductase, a key enzyme in cholesterol synthesis. This inhibition enhances the livers synthesis LDL receptors. The latter, discovered by Brown and Goldstein , remove LDL and VLDL from the bloodstream, which lower serum cholesterol. Statin have proven to be highly efficacious with few side effects. The development of statins as a cholesterol-lowering drug has been actively pursued by the pharmaceutical industry. Several statins have been approved for use in clinical practice by the FDA. Over the past three decades, a series of RCTs have been carried out that documents the efficacy and safety of statin therapy. In these RCTs, statin therapy has been shown to significantly reduce morbidity and mortality from ASCVD. Although individual RCTs produced significant results, the strongest evidence of benefit comes from meta-analysis. i.e., by combining data from all the trials .

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