Re: Hypercholesterolemia and Hypertension

[Guest guest]

Nick Tatalias wrote:

> A question which interests me is if someone has a high cholesterol

or >a high systolic blood pressure due to genetic dispossession is

this as >serious in terms of motality studies as opposed to someone

who has >these high levels due to poor lifestyle choice? Is

medication >necessary in all cases?

****

I must admit I have certainly wondered the same thing about high

systolic pressures over the years considering that under exercise

stress systolic blood pressure (at top of pump) gets up to around 160-

180 and probably higher if you start higher. Diastolic pressure (rest

between beats) tends to stay the same - as I understand it and from

experience. So if one trains regularly, say an hour/day, is this

extra systolic pressure dangerous? Apparently not. Exercise tends to

lower pressure for some time after, so I guess overall pressure over

time is lower.

High blood pressure seems to damage artery walls and affect plaque

deposits in arteries. So, I guess it is a continuum in which risk

accumulates according to lifestyle risk factors. For example, high

blood pressure plus high cholesterol plus overweight is an accident

waiting to happen. What the risk may be with only high systolic

pressure as a risk factor is a black box, but it's probably higher

than someone with lower blood pressure.

As far as blood cholesterol is concerned, the risk starts to climb

from about 150 mg/dL total cholesterol and 100 mg/dL or lower of LDL

cholesterol. Below this, incidence of heart disease over the long

term is very low from what I can make of Framingham and other more

recent studies. High HDL, the good cholesterol, is also protective.

(See Ralph's post recently.) It's worth being aware that there is

quite a concerted campaign by 'cholesterol skeptics' to try to prove

that cholesterol is not a factor in heart disease. They are wrong.

However, that is not to say that there may not be a lifestyle

approach that provides protection at higher cholesterol levels, say

with Mediterranean diet, exercise, a red wine or twelve . . .;-). The

so-called French paradox, in which some Europeans seem to have low

levels of cardiovascular disease with higher cholesterol levels,

seems to suggest something is going on -- but it may be genetics.

Apologies for the long answer, but I'd say that exercise or other

lifestyle factors generally does not protect from the risks of high

cholesterol (although high HDL may negate risk to some extent). Two

of my mates, long-term heavy exercisers, can attest to that, although

it may have saved their lives.

Hope this helps.

Gympie, Australia

[Guest guest]

Thanks for the comments on Higher Systolic BP readings.

With regards Cholesterol you wrote

" As far as blood cholesterol is concerned, the risk starts to climb

from about 150 mg/dL total cholesterol and 100 mg/dL or lower of LDL

cholesterol. Below this, incidence of heart disease over the long

term is very low from what I can make of Framingham and other more

recent studies. High HDL, the good cholesterol, is also protective.

(See Ralph's post recently.) It's worth being aware that there is

quite a concerted campaign by 'cholesterol skeptics' to try to prove

that cholesterol is not a factor in heart disease. They are wrong. "

With regards to cholesterol, my mother in law has a slightly elevated

cholesterol level (7mmol/l) levels are considered high from 5mmol/l, but as

far as I can tell no other risk factors. She is healthy, active (very

passionate gardener), doesn't smoke, drinks alcohol in minor quantities, has

normal blood pressure, eats mostly quite well lots of fruit and veggies.

She is in her late 60's. I don't know the split between HDL and LDL. Her

doctor (a new doctor due to medical insurance requirements) has placed her

on Statins to help with cholesterol. Her previous doctor did not see the

need for medication. I have asked her to supplement her diet with omega 3

capsules (by GNLD which are supposed to be checked to be free of dangerous

metals) to try to help the HDL levels precisely because they provide

protection. The cholesterol skeptics point to a study in which they show

that mortality in older woman is inversely related to cholesterol levels.

You mention that the cholesterol skeptics are wrong, what is wrong with

their rational.

My question is why does a seemingly healthy person require drugs to control

their cholesterol when there are no other indications of disease. Is this

doctor doing the right thing?

Best Regards

Nick Tatalias

Johannesburg

South Africa

(Ps the only team that normally does worse than the Reds is the Lions

(formally Cats) not sure what to recommend, perhaps move to Christchurch NZ

and support the local team :-)

[Guest guest]

>

> With regards to cholesterol, my mother in law has a slightly

elevated

> cholesterol level (7mmol/l) levels are considered high from

5mmol/l, but as

> far as I can tell no other risk factors. She is healthy, active

(very

> passionate gardener), doesn't smoke, drinks alcohol in minor

quantities, has

> normal blood pressure, eats mostly quite well lots of fruit and

veggies.

> She is in her late 60's. I don't know the split between HDL and

LDL. Her

> doctor (a new doctor due to medical insurance requirements) has

placed her

> on Statins to help with cholesterol. Her previous doctor did not

see the

> need for medication. I have asked her to supplement her diet with

omega 3

> capsules (by GNLD which are supposed to be checked to be free of

dangerous

> metals) to try to help the HDL levels precisely because they provide

> protection. The cholesterol skeptics point to a study in which

they show

> that mortality in older woman is inversely related to cholesterol

levels.

> You mention that the cholesterol skeptics are wrong, what is wrong

with

> their rational.

>

> My question is why does a seemingly healthy person require drugs to

control

> their cholesterol when there are no other indications of disease.

Is this

> doctor doing the right thing?

Nick, it's difficult to comment on the statins issue and your mother

in law, other than to say that statins now seem to have a good record

of safety and efficacy after some early problems with muscle effects.

It's a judgement call by her doctor. Some doctors may apply the

treatment protocols a little more strictly than others.

Re cholesterol skeptics and mortality studies of low cholesterol, you

will also see studies that cancer and suicide incidence is higher

with lower cholesterol. Just about all of these studies can be

explained by the fact that the old, infirm, ill, smokers and people

with disease and depression will often have lower cholesterol numbers

because of their illnesses or inadequate nutrition. Such studies need

to control for these confounding factors. Fit and healthy people with

low cholesterol would provide a different picture.

However, from what I have seen, bleeding strokes (hemorrhagic) may be

a little higher in people with low cholesterol. But you will get this

with anything that increases blood flow -- aspirin, warfarin,

probably fish oil as well. Even so, you lower the risk of a clotting

stroke (ischemic) at the same time. It's a balance.

> (Ps the only team that normally does worse than the Reds is

the Lions

> (formally Cats) not sure what to recommend, perhaps move to

Christchurch NZ

> and support the local team :-)

[i just want everyone to know that I don't have anything to do with

training the Reds! <g>]

Gympie, Australia

[Guest guest]

Nick,

with regards to your mother in laws lipid profile it

is very important to know what the specific LDL and

the HDL. Total cholesterol levels are meaningless

without knowing the the make up of the individual

components.

As pointed out the LDL should be less than 130 in

an other wise healthy individual and less than 100 in

an individual with other risk factors such a Diabetes

or previous heart disease.

The HDL should be greater than 40 in men and greater

than 50 in women. What is often overlooked in this

type of discussion is the level of Triglycerides.

These levels should be less than 160.

Unfortunately, since we do not use moles as a method

of measurement in the USA I have no idea what to make

of the numbers you quoted. I tried finding a

conversion of moles to mg/dl but was not able to find

the appropriate conversion tables.

The total cholesterol is made up of the sum of the HDL

and LDL plus 20% of the total triglyceride.

An HDL of 40 plus LDL of 130 and 20% of a triglyceride

of 150 (30) would equal a total cholesterol of 200.

I should note here that generally the LDL levels are

not measured directly but are calculated by taking the

HDL level plus 20% of the triglycerides and

subtracting this sum from the total cholesterol. LDL

levels can be measured directly but the process is

more expensive.

I have seen individuals (especially women) with HDL

levels of 80-100+. If we use the example above and

substitute and HDL of 80 for the HDL of 40 we would

get a total cholesterol of 240. In this case the

total cholesterol is not only normal but very good

because of the inordinately high HDL.

On the other hand if we had an HDL of 20 and LDL of

150 along with a triglyceride of 150 we would get a

total cholesterol of 200 which would not be good at

all because of the abnormally low HDL and relatively

high LDL.

Finally an individual may have a normal HDL and LDL

but an abnormally high Triglyceride. I have seen

individuals with Triglycerides as high as 2000 (two

thousand).

As for Omega 3 it does a very good job at lowering

triglycerides, a bad job of lowering the LDL and a

poor job at raising the HDL.

<<Triglyceride Lowering

Omega-3 fatty acids reduce triglyceride concentrations

in a dose dependent manner, with intakes of about 4 g

per day lowering serum triglycerides by 25-30%. The

hypo-triglyceridaemic effects of omega-3 fatty acids

from fish oils are well established. In a

comprehensive review of human studies, [41]

reported that 4 g/day of omega-3 fatty acids from fish

oil decreased serum triglyceride concentrations by

25-30%. There were accompanying increases in low

density lipoprotein (LDL) cholesterol of 5-10%, in

high density lipoprotein (HDL) cholesterol of 1-3% and

a dose-response relationship between omega-3 fatty

acid intake and triglyceride lowering. Postprandial

triglyceridaemia is especially sensitive to chronic

omega-3 fatty acid consumption, with quite small

intakes (2 g/day) producing significant

reductions.[42]

Omacor is licensed in the dose of 2-4 g/day for the

treatment of endogenous hypertriglyceridaemia as a

supplement to diet when dietary measures alone are

insufficient to produce an adequate response: - type

IV in monotherapy, - type IIb/III in combination with

statins, when control of triglyceride levels is

insufficient.

" The Mechanism of Action of Omega-3 Fatty Acids in

Secondary Prevention Post-Myocardial Infarction

Nigel on; Brihad Abhyankar

Curr Med Res Opin. 2005;21(1):95-100. ©2005

Librapharm Limited

Posted 03/16/2005 >>

There are other benefits to the use Omega -3 and I

would recommend the above article for further

information.

Before anyone can intelligently comment on your mother

in law's treatment it is important to know what the

break down is and if there are any other risk factor's

such as family history of heart disease, hypertension

etc.

Her first physician may be using older less aggressive

recommendations for treatment and the new physician

may be using the newer more aggressive

recommendations.

Ralph Giarnella MD

Southington Ct USA

--- Nick Tatalias wrote:

> Thanks for the comments on Higher Systolic BP

> readings.

>

> With regards Cholesterol you wrote

> " As far as blood cholesterol is concerned, the risk

> starts to climb

> from about 150 mg/dL total cholesterol and 100 mg/dL

> or lower of LDL

> cholesterol. Below this, incidence of heart disease

> over the long

> term is very low from what I can make of Framingham

> and other more

> recent studies. High HDL, the good cholesterol, is

> also protective.

> (See Ralph's post recently.) It's worth being aware

> that there is

> quite a concerted campaign by 'cholesterol skeptics'

> to try to prove

> that cholesterol is not a factor in heart disease.

> They are wrong. "

>

> With regards to cholesterol, my mother in law has a

> slightly elevated

> cholesterol level (7mmol/l) levels are considered

> high from 5mmol/l, but as

> far as I can tell no other risk factors. She is

> healthy, active (very

> passionate gardener), doesn't smoke, drinks alcohol

> in minor quantities, has

> normal blood pressure, eats mostly quite well lots

> of fruit and veggies.

> She is in her late 60's. I don't know the split

> between HDL and LDL. Her

> doctor (a new doctor due to medical insurance

> requirements) has placed her

> on Statins to help with cholesterol. Her previous

> doctor did not see the

> need for medication. I have asked her to supplement

> her diet with omega 3

> capsules (by GNLD which are supposed to be checked

> to be free of dangerous

> metals) to try to help the HDL levels precisely

> because they provide

> protection. The cholesterol skeptics point to a

> study in which they show

> that mortality in older woman is inversely related

> to cholesterol levels.

> You mention that the cholesterol skeptics are wrong,

> what is wrong with

> their rational.

>

> My question is why does a seemingly healthy person

> require drugs to control

> their cholesterol when there are no other

> indications of disease. Is this

> doctor doing the right thing?

>

> Best Regards

> Nick Tatalias

> Johannesburg

> South Africa

>

> (Ps the only team that normally does worse than

> the Reds is the Lions

> (formally Cats) not sure what to recommend, perhaps

> move to Christchurch NZ

> and support the local team :-)

>

>

[Guest guest]

Thanks Ralph

I will read your reference.

From Wikipedia http://en.wikipedia.org/wiki/Cholesterol

*Level* mg

<http://en.wikipedia.org/wiki/Milligram>/dL<http://en.wikipedia.org/wiki/Decilit\

re>

*Level* mmol

<http://en.wikipedia.org/wiki/Mole_%28unit%29>/L<http://en.wikipedia.org/wiki/Li\

tre>

*Interpretation* <200 <5.2 Desirable level corresponding to lower risk for

heart disease 200-239 5.2-6.2 Borderline high risk >240 >6.2 High risk

She is in the high risk category her levels being equivalent to alevel

greater than 240mg/dl

I have read quite a lot now and can at least go and ask the right

questions. In my opinion her new physician is not up there on the list of

doctors I would trust, but that's my opinion. I will try to look at tother

factors, but from my knowledge she is not at risk on the other factors, with

her age being the only risk factor other than the high cholesterol. I will

endevour to find other information and ask questions of the physician.

Best Regards

Nick Tatalias

Johannesburg

South Africa

>

> Nick,

> with regards to your mother in laws lipid profile it

> is very important to know what the specific LDL and

> the HDL. Total cholesterol levels are meaningless

> without knowing the the make up of the individual

> components.

>

> As pointed out the LDL should be less than 130 in

> an other wise healthy individual and less than 100 in

> an individual with other risk factors such a Diabetes

> or previous heart disease.

>

> The HDL should be greater than 40 in men and greater

> than 50 in women. What is often overlooked in this

> type of discussion is the level of Triglycerides.

> These levels should be less than 160.

>

> Unfortunately, since we do not use moles as a method

> of measurement in the USA I have no idea what to make

> of the numbers you quoted. I tried finding a

> conversion of moles to mg/dl but was not able to find

> the appropriate conversion tables.

>

> The total cholesterol is made up of the sum of the HDL

> and LDL plus 20% of the total triglyceride.

>

> An HDL of 40 plus LDL of 130 and 20% of a triglyceride

> of 150 (30) would equal a total cholesterol of 200.

>

> I should note here that generally the LDL levels are

> not measured directly but are calculated by taking the

> HDL level plus 20% of the triglycerides and

> subtracting this sum from the total cholesterol. LDL

> levels can be measured directly but the process is

> more expensive.

>

> I have seen individuals (especially women) with HDL

> levels of 80-100+. If we use the example above and

> substitute and HDL of 80 for the HDL of 40 we would

> get a total cholesterol of 240. In this case the

> total cholesterol is not only normal but very good

> because of the inordinately high HDL.

>

> On the other hand if we had an HDL of 20 and LDL of

> 150 along with a triglyceride of 150 we would get a

> total cholesterol of 200 which would not be good at

> all because of the abnormally low HDL and relatively

> high LDL.

>

> Finally an individual may have a normal HDL and LDL

> but an abnormally high Triglyceride. I have seen

> individuals with Triglycerides as high as 2000 (two

> thousand).

>

> As for Omega 3 it does a very good job at lowering

> triglycerides, a bad job of lowering the LDL and a

> poor job at raising the HDL.

>

> <<Triglyceride Lowering

>

> Omega-3 fatty acids reduce triglyceride concentrations

> in a dose dependent manner, with intakes of about 4 g

> per day lowering serum triglycerides by 25-30%. The

> hypo-triglyceridaemic effects of omega-3 fatty acids

> from fish oils are well established. In a

> comprehensive review of human studies, [41]

> reported that 4 g/day of omega-3 fatty acids from fish

> oil decreased serum triglyceride concentrations by

> 25-30%. There were accompanying increases in low

> density lipoprotein (LDL) cholesterol of 5-10%, in

> high density lipoprotein (HDL) cholesterol of 1-3% and

> a dose-response relationship between omega-3 fatty

> acid intake and triglyceride lowering. Postprandial

> triglyceridaemia is especially sensitive to chronic

> omega-3 fatty acid consumption, with quite small

> intakes (2 g/day) producing significant

> reductions.[42]

>

> Omacor is licensed in the dose of 2-4 g/day for the

> treatment of endogenous hypertriglyceridaemia as a

> supplement to diet when dietary measures alone are

> insufficient to produce an adequate response: - type

> IV in monotherapy, - type IIb/III in combination with

> statins, when control of triglyceride levels is

> insufficient.

>

> " The Mechanism of Action of Omega-3 Fatty Acids in

> Secondary Prevention Post-Myocardial Infarction

>

> Nigel on; Brihad Abhyankar

> Curr Med Res Opin. 2005;21(1):95-100. ©2005

> Librapharm Limited

> Posted 03/16/2005 >>

>

> There are other benefits to the use Omega -3 and I

> would recommend the above article for further

> information.

>

> Before anyone can intelligently comment on your mother

> in law's treatment it is important to know what the

> break down is and if there are any other risk factor's

> such as family history of heart disease, hypertension

> etc.

>

> Her first physician may be using older less aggressive

> recommendations for treatment and the new physician

> may be using the newer more aggressive

> recommendations.

>

> Ralph Giarnella MD

> Southington Ct USA

>

> --- Nick Tatalias <nick.tatalias@... <nick.tatalias%40gmail.com>>

> wrote:

>

> > Thanks for the comments on Higher Systolic BP

> > readings.

> >

> > With regards Cholesterol you wrote

> > " As far as blood cholesterol is concerned, the risk

> > starts to climb

> > from about 150 mg/dL total cholesterol and 100 mg/dL

> > or lower of LDL

> > cholesterol. Below this, incidence of heart disease

> > over the long

> > term is very low from what I can make of Framingham

> > and other more

> > recent studies. High HDL, the good cholesterol, is

> > also protective.

> > (See Ralph's post recently.) It's worth being aware

> > that there is

> > quite a concerted campaign by 'cholesterol skeptics'

> > to try to prove

> > that cholesterol is not a factor in heart disease.

> > They are wrong. "

> >

> > With regards to cholesterol, my mother in law has a

> > slightly elevated

> > cholesterol level (7mmol/l) levels are considered

> > high from 5mmol/l, but as

> > far as I can tell no other risk factors. She is

> > healthy, active (very

> > passionate gardener), doesn't smoke, drinks alcohol

> > in minor quantities, has

> > normal blood pressure, eats mostly quite well lots

> > of fruit and veggies.

> > She is in her late 60's. I don't know the split

> > between HDL and LDL. Her

> > doctor (a new doctor due to medical insurance

> > requirements) has placed her

> > on Statins to help with cholesterol. Her previous

> > doctor did not see the

> > need for medication. I have asked her to supplement

> > her diet with omega 3

> > capsules (by GNLD which are supposed to be checked

> > to be free of dangerous

> > metals) to try to help the HDL levels precisely

> > because they provide

> > protection. The cholesterol skeptics point to a

> > study in which they show

> > that mortality in older woman is inversely related

> > to cholesterol levels.

> > You mention that the cholesterol skeptics are wrong,

> > what is wrong with

> > their rational.

> >

> > My question is why does a seemingly healthy person

> > require drugs to control

> > their cholesterol when there are no other

> > indications of disease. Is this

> > doctor doing the right thing?

> >

> > Best Regards

> > Nick Tatalias

> > Johannesburg

> > South Africa

> >

> > (Ps the only team that normally does worse than

> > the Reds is the Lions

> > (formally Cats) not sure what to recommend, perhaps

> > move to Christchurch NZ

> > and support the local team :-)

> >

> >

>

>

>

[Guest guest]

>

> Unfortunately, since we do not use moles as a method

> of measurement in the USA I have no idea what to make

> of the numbers you quoted. I tried finding a

> conversion of moles to mg/dl but was not able to find

> the appropriate conversion tables.

Conversion of cholesterol mg/dL to mmol/L divide by 38.7

Conversion of triglycerides mg/dL to mmol/L divide by 88.6

.. . . give or take a few points.

I work in both units. Conversions written on the side of my processor!

Gympie, Australia

[Guest guest]

>

> Unfortunately, since we do not use moles as a method

> of measurement in the USA I have no idea what to make

> of the numbers you quoted. I tried finding a

> conversion of moles to mg/dl but was not able to find

> the appropriate conversion tables.

Conversion of cholesterol mg/dL to mmol/L divide by 38.7

Conversion of triglycerides mg/dL to mmol/L divide by 88.6

.. . . give or take a few points.

I work in both units. Conversions written on the side of my processor!

Gympie, Australia

[Guest guest]

The following article is pertinent to the present

discussion:

Ralph Giarnella MD

Southington Ct USA

******************

High Cholesterol Linked With Stroke Even in Healthy

Women CME/CE

News Author:

CME Author: Désirée Lie, MD, MSEd

Disclosures

Release Date: February 22, 2007; Valid for credit

through February 22, 2008

Credits Available

Physicians - maximum of 0.25 AMA PRA Category 1

Credit(s)™ for physicians;

Family Physicians - up to 0.25 AAFP Prescribed

credit(s) for physicians;

Nurses - 0.25 nursing contact hours (None of these

credits is in the area of pharmacology)

February 22, 2007 — A new report from the Women's

Health Study confirms that high levels of total

cholesterol, low-density lipoprotein–cholesterol

(LDL-C), and other lipid levels are significantly

associated with an increased risk for ischemic stroke,

even in women who are otherwise healthy.

" We did not look at people with high risk for

cardiovascular disease or with existing cardiovascular

disease, but among women who were apparently healthy, "

lead author Tobias Kurth, MD, ScD, of Brigham and

Women's Hospital, Harvard Medical School in Boston,

Massachusetts, told Medscape. " That means even when

you're fine, you should really watch your cholesterol,

and by approaching low cholesterol levels, you may

prevent risk for ischemic stroke. "

Their report appears in the February 20 issue of

Neurology.

A More Complex Relationship?

That levels of total cholesterol and all lipid

fractions are related to the risk for ischemic heart

disease is well-established, Dr. Kurth said. The

relationship with the risk for stroke and transient

ischemic attack (TIA) has been less clear. Randomized

trials, for example, have shown that lipid-lowering

treatment with statins reduces the risk for stroke in

patients with a history of stroke or TIAs and among

those at high risk for these events.

However, the epidemiologic literature is less

consistent. Some studies have found a relationship

between ischemic stroke and total cholesterol for

example, and some have not, the authors write. A

relationship between high-density lipoprotein

cholesterol (HDL-C) and stroke has been shown in

several studies, they note, " but the association

between low-density lipoprotein cholesterol (LDL-C)

and ischemic stroke is less studied and inconsistent. "

In this study, Dr. Kurth and colleagues used data from

the Women's Health Study, a randomized clinical trial

of low-dose aspirin and vitamin E in the primary

prevention of cardiovascular disease and cancer in

women free from these diseases at baseline. For this

analysis, they used data from 27,937 of these women

aged 45 years or older who had provided baseline blood

samples. Stroke occurrence was self-reported and

confirmed by medical record review.

During 11 years of follow-up, 282 ischemic stroke

events occurred. The researchers report that after

adjustment for age, all lipid levels, including total

cholesterol, LDL-C, HDL-C, total cholesterol:HDL-C

ratio, and non-HDL-C, were strongly associated with

subsequent risk for ischemic stroke. After adjustment

for a number of potential confounders, all

associations remained significant, except for HDL-C,

although they point out that the point estimate still

suggested a protective association.

Table. Women's Health Study: Ischemic Stroke Risk for

Highest vs Lowest Quintile of Total Cholesterol and

Cholesterol Fractions*

Measure Hazard Ratio 95% CI P for

Trend

Total cholesterol 2.27 1.43 - 3.60 <

..001

LDL-C 1.74 1.14 - 2.66

..003

HDL-C 0.78 0.52 - 1.17

..27

Total cholesterol

to HDL-C ratio 1.65 1.06 - 2.58

..02

Non-HDL-C 2.45 1.54 - 3.91 <

..001

*CI indicates confidence interval; LDL-C, low-density

lipoprotein cholesterol; and HDL-C, high-density

lipoprotein cholesterol.

Source: Neurology. 2007;68:556-562.

The association between ischemic stroke and total

cholesterol was not modified by age, smoking status,

history of hypertension, body mass index (BMI), or

randomized aspirin assignment, although it was

modified by postmenopausal hormone use. The risk for

stroke associated with total cholesterol was only seen

in those not taking postmenopausal hormones.

In addition, the relationship between stroke and all

of these lipid levels was attenuated by adjustment for

factors that both affect lipid levels and are

themselves risk factors for stroke: exercise, alcohol

consumption, smoking, and BMI, suggesting that this

may be the mechanism by which lipid levels affect

stroke risk, they speculate. " The strong influence of

these behavioral factors on HDL-C levels may be part

of the reason why HDL-C was not strongly associated

with the risk for ischemic stroke after multivariable

adjustment, " Dr. Kurth and colleagues write. In fact,

when these factors were excluded, a significant

relationship between ischemic stroke and HDL-C

emerged, they point out.

" The data of the randomized trials, the data of

others, and our data strongly support the notion that

lipids are a biologic risk factor for ischemic stroke

and that avoiding unfavorable cholesterol levels may

help to prevent ischemic stroke as recommended (by)

the primary prevention guidelines of the American

Heart Association/American Stroke Association, " the

authors conclude. " Our results further underscore the

importance of unfavorable lipid levels as risk factors

for first ischemic stroke among apparently healthy

individuals without prior vascular disease. "

The study was supported by the National Heart, Lung,

and Blood Institute and the National Cancer Institute

in Bethesda, land, and grants from the W.

Reynolds Foundation and the Leducq Foundation.

Neurology. 2007;68:556-562.

Clinical Context

According to the current authors, trials of statin use

have demonstrated protection against ischemic stroke

among patients with existing strokes or TIAs, and some

observational studies have found increasing risk for

stroke with increasing total cholesterol levels. But

while an association has been found between low HDL-C

levels and ischemic stroke risk, the association of

stroke with other lipid measures, such as LDL-C, is

uncertain.

This is a longitudinal cohort study within the Women's

Health Study of health professionals to determine the

value of lipid parameters as predictors of stroke risk

in women who were healthy at baseline and who were

followed up for a mean of 11 years.

Study Highlights

Included were 27,937 women who were registered health

professionals in the United States or Puerto Rico aged

45 years or older without cardiovascular disease,

cancer, or major illness, who were subsequently

randomly assigned to aspirin, vitamin E, both, or

neither, and who had blood drawn at baseline for

cholesterol measurements (lipid panel).

Women were sent questionnaires twice in the first year

and yearly thereafter asking about study outcomes,

including stroke.

Participants who reported stroke had their medical

records reviewed for confirmation of diagnosis.

Nonfatal stroke was defined as a new focal neurologic

deficit over 24 hours in duration.

Fatal stroke was defined by evidence of

cerebrovascular mechanism obtained from autopsy,

medical records, family members, or diagnostic tests.

The type of stroke (ischemic vs hemorrhagic) was

determined by results of diagnostic tests.

The association between cholesterol measures and

stroke was determined by age (younger than 55, 55 to

64, 65 years and older), history of hypertension, BMI,

smoking status, current menopausal status, and aspirin

assignment.

Mean age was 55 years, 95% were white, and 13% had

vocational nursing training.

Women in the lowest quintile of total cholesterol had

levels less than 179 mg/dL, and those in the highest

quintile had levels higher than 244 mg/dL.

Those in the highest quintile had higher BMI, blood

pressure (BP), and were more likely to have

hypertension, diabetes, or migraine and to smoke.

During 11 years of follow-up (307,769 person years), a

total of 282 ischemic strokes were reported.

Compared with women in the lowest quintile, those in

the highest quintile had adjusted hazard ratios (HRs)

of ischemic stroke of 2.27 for total cholesterol, 1.74

for LDL-C, 0.78 for HDL-C, 1.65 for total to HDL-C

ratio, and 2.45 for non-HDL-C.

Additional adjustment for systolic BP and

antihypertensive or aspirin use attenuated the

association, but the association remained strong.

For every 1-mmol/dL (38.7-mg/dL) increase in

cholesterol, the adjusted HR was 1.17 for total

cholesterol, 1.15 for LDL-C, 0.91 for HDL-C, and 1.19

for non-HDL-C.

The best predictive model for ischemic stroke

incorporated non-HDL-C followed by the model that

included total cholesterol and one that included

LDL-C.

Thus, the strongest predictor of stroke risk among

cholesterol measures was non-HDL-C followed by total

cholesterol followed by LDL-C.

The association between total cholesterol and ischemic

stroke was not modified by age, smoking status, BMI,

history of hypertension, or aspirin assignment but was

modified by current postmenopausal hormone use.

Women who used postmenopausal hormones did not show

the increased risk for ischemic stroke with increasing

total cholesterol.

The authors noted that other studies have also

identified non-HDL-C as a strong predictor of coronary

and overall cardiovascular disease.

Pearls for Practice

In healthy women, total, HDL-C, non-HDL-C, and LDL-C

levels are all predictors of ischemic stroke risk

during 11 years of follow-up.

The strongest cholesterol predictor of ischemic stroke

risk for women is non-HDL-C followed by total

cholesterol followed by LDL-C.

[Guest guest]

Attached is another releveant article.

Ralph Giarnella MD

Southington Ct USA

*************************

Cardiac Mortality Drop Attributed to Therapies and

Risk Factor Reductions

By Neil Osterweil, Senior Associate Editor, MedPage

Today

Reviewed by Jasmer, MD; Associate Clinical

Professor of Medicine, University of California, San

Francisco

June 06, 2007

Add Your Knowledge™ Additional Coronary Artery

Disease Coverage

ATLANTA, June 6 -- Credit for the near halving of the

rate of coronary disease deaths in the U.S, from 1980

to 2000, belongs equally to reductions in risk factors

and to the rise of evidence-based therapies, found CDC

and British researchers.

Action Points

Explain to patients that quitting smoking, lowering

LDL cholesterol, controlling blood pressure and

increasing physical activity can all significantly

lower their risk for death from coronary heart

disease.

There were 341,745 fewer deaths from coronary heart

disease in 2000 than in 1980, and about 47% of that

decline can be attributed to primary and secondary

medical therapies and interventions, they reported in

the June 7 issue of the New England Journal of

Medicine.

Reductions in risk factors such as smoking, high

cholesterol, hypertension and inactivity get the nod

for an additional 44% of the drop in coronary heart

disease mortality, according to Earl S. Ford, M.D.,

M.P.H., of the National Center for Chronic Disease

Prevention and Health Promotion, and colleagues.

But they also found that two major factors prevented

the decreases in deaths from being even greater.

" Our analysis estimated that increases in the

body-mass index accounted overall for about 26,000

additional deaths from coronary heart disease in 2000,

and increases in the prevalence of diabetes for about

33,500 additional deaths; both figures are consistent

with the results of other recent studies, " they wrote.

" Efforts to address these two risk factors should

therefore receive particular attention in future

measures to improve the public health. "

The investigators used a previously validated

statistical model called IMPACT to analyze the

relative contributions of risk factor reduction,

medical therapies, and interventions such as coronary

artery bypass graft (CABG) and percutaneous

transluminal coronary angioplasty to the decline in

coronary disease-related deaths. The analyses were

conducted at the University of Liverpool in England.

The difference between the expected and actual number

of deaths from coronary heart disease in 2000 versus

1980 was distributed proportionally among the various

treatments and risk factors included in the analyses.

They employed primarily data sources that were

specific to the U.S. population, using the most

up-to-date, least biased, and most representative

sources whenever possible.

They found that the age-adjusted death rate for

coronary heart disease among men fell from 542.9

deaths per 100,000 in 1980 to 266.8 per 100,000 in

2000. Among women, the rate fell from 263.3 per

100,000 in 1980 to 134.4 deaths per 100,000 in 2000.

The total difference in observed vs. expected deaths

in 2000 was 341,745.

About 47% of the decrease (159,330 fewer deaths) was

attributed to treatments as follows:

Secondary preventive therapies after myocardial

infarction or revascularization, 11%,

Initial treatments for acute myocardial infarction or

unstable angina 10%,

Treatments for heart failure, 9%,

Revascularization for chronic angina, 5%,

Other therapies 12%.

An additional 44% of the drop could be attributed to

the following changes in risk factors (numbers

represent percentage of total reduction, and overlap):

Reductions in total cholesterol, 24%,

Decrease in systolic blood pressure, 20%,

Decline in smoking prevalence, 12%,

Reduction in physical inactivity, 5%.

Progress in risk factor reductions was partially

offset, however, by an 8% increase in body-mass index

over the two decades, by a 10% rise in the prevalence

of diabetes, the authors noted.

" Irrespective of the assumptions used, we found that

the largest contributions from medical therapies

consistently came from secondary prevention, followed

by treatments for acute coronary syndromes, then heart

failure, " they wrote. " Revascularization by means of

CABG or angioplasty for stable or unstable disease

together accounted for approximately 7% of the overall

drop in deaths from coronary heart disease, a finding

that is consistent with the results of previous

studies in the United States and elsewhere. "

They noted that possible study limitations included

the use of data from various sources, including some

studies that might have been limited by ethnic,

geographic, or selections biases. They also noted that

most of varying quality o and the averaging of

interactions across broad groups, although the

analyses were limited only to reductions in deaths,

and did not include quality-of-life measures

[Guest guest]

HI Ralph

Thanks for this post. What I find really interesting is this statement

" although it was modified by postmenopausal hormone use. The risk for

stroke associated with total cholesterol was only seen in those not taking

postmenopausal hormones. "

From Wikipedia

It is the major precursor for the synthesis of vitamin

D<http://en.wikipedia.org/wiki/Vitamin_D>and of the various steroid

hormones <http://en.wikipedia.org/wiki/Steroid_hormone> (which include

cortisol <http://en.wikipedia.org/wiki/Cortisol> and

aldosterone<http://en.wikipedia.org/wiki/Aldosterone>in the adrenal

glands <http://en.wikipedia.org/wiki/Adrenal_gland>, and the sex hormones

progesterone <http://en.wikipedia.org/wiki/Progesterone>, the various

estrogens <http://en.wikipedia.org/wiki/Estrogen>,

testosterone<http://en.wikipedia.org/wiki/Testosterone>,

and derivatives).

Is it possible that since the function of hormone manufacture has been

replaced bytheHRT that this may link to higher lipid profile, but also for

its less devistating effect.

My mother in law is on HRT and this interests me. What do you think?

Best Rgeards

Nick Tatalias

Johannesburg

South Africa

>

> The following article is pertinent to the present

> discussion:

> Ralph Giarnella MD

> Southington Ct USA

>

> ******************

> High Cholesterol Linked With Stroke Even in Healthy

> Women CME/CE

> News Author:

> CME Author: Désirée Lie, MD, MSEd

> Disclosures

>

> Release Date: February 22, 2007; Valid for credit

> through February 22, 2008

> Credits Available

>

> Physicians - maximum of 0.25 AMA PRA Category 1

> Credit(s)™ for physicians;

> Family Physicians - up to 0.25 AAFP Prescribed

> credit(s) for physicians;

> Nurses - 0.25 nursing contact hours (None of these

> credits is in the area of pharmacology)

>

> February 22, 2007 — A new report from the Women's

> Health Study confirms that high levels of total

> cholesterol, low-density lipoprotein–cholesterol

> (LDL-C), and other lipid levels are significantly

> associated with an increased risk for ischemic stroke,

> even in women who are otherwise healthy.

>

> " We did not look at people with high risk for

> cardiovascular disease or with existing cardiovascular

> disease, but among women who were apparently healthy, "

> lead author Tobias Kurth, MD, ScD, of Brigham and

> Women's Hospital, Harvard Medical School in Boston,

> Massachusetts, told Medscape. " That means even when

> you're fine, you should really watch your cholesterol,

> and by approaching low cholesterol levels, you may

> prevent risk for ischemic stroke. "

>

> Their report appears in the February 20 issue of

> Neurology.

>

> A More Complex Relationship?

>

> That levels of total cholesterol and all lipid

> fractions are related to the risk for ischemic heart

> disease is well-established, Dr. Kurth said. The

> relationship with the risk for stroke and transient

> ischemic attack (TIA) has been less clear. Randomized

> trials, for example, have shown that lipid-lowering

> treatment with statins reduces the risk for stroke in

> patients with a history of stroke or TIAs and among

> those at high risk for these events.

>

> However, the epidemiologic literature is less

> consistent. Some studies have found a relationship

> between ischemic stroke and total cholesterol for

> example, and some have not, the authors write. A

> relationship between high-density lipoprotein

> cholesterol (HDL-C) and stroke has been shown in

> several studies, they note, " but the association

> between low-density lipoprotein cholesterol (LDL-C)

> and ischemic stroke is less studied and inconsistent. "

>

> In this study, Dr. Kurth and colleagues used data from

> the Women's Health Study, a randomized clinical trial

> of low-dose aspirin and vitamin E in the primary

> prevention of cardiovascular disease and cancer in

> women free from these diseases at baseline. For this

> analysis, they used data from 27,937 of these women

> aged 45 years or older who had provided baseline blood

> samples. Stroke occurrence was self-reported and

> confirmed by medical record review.

>

> During 11 years of follow-up, 282 ischemic stroke

> events occurred. The researchers report that after

> adjustment for age, all lipid levels, including total

> cholesterol, LDL-C, HDL-C, total cholesterol:HDL-C

> ratio, and non-HDL-C, were strongly associated with

> subsequent risk for ischemic stroke. After adjustment

> for a number of potential confounders, all

> associations remained significant, except for HDL-C,

> although they point out that the point estimate still

> suggested a protective association.

>

> Table. Women's Health Study: Ischemic Stroke Risk for

> Highest vs Lowest Quintile of Total Cholesterol and

> Cholesterol Fractions*

>

> Measure Hazard Ratio 95% CI P for

> Trend

> Total cholesterol 2.27 1.43 - 3.60 <

> .001

> LDL-C 1.74 1.14 - 2.66

> .003

> HDL-C 0.78 0.52 - 1.17

> .27

>

> Total cholesterol

> to HDL-C ratio 1.65 1.06 - 2.58

> .02

>

> Non-HDL-C 2.45 1.54 - 3.91 <

> .001

>

> *CI indicates confidence interval; LDL-C, low-density

> lipoprotein cholesterol; and HDL-C, high-density

> lipoprotein cholesterol.

> Source: Neurology. 2007;68:556-562.

>

> The association between ischemic stroke and total

> cholesterol was not modified by age, smoking status,

> history of hypertension, body mass index (BMI), or

> randomized aspirin assignment, although it was

> modified by postmenopausal hormone use. The risk for

> stroke associated with total cholesterol was only seen

> in those not taking postmenopausal hormones.

>

> In addition, the relationship between stroke and all

> of these lipid levels was attenuated by adjustment for

> factors that both affect lipid levels and are

> themselves risk factors for stroke: exercise, alcohol

> consumption, smoking, and BMI, suggesting that this

> may be the mechanism by which lipid levels affect

> stroke risk, they speculate. " The strong influence of

> these behavioral factors on HDL-C levels may be part

> of the reason why HDL-C was not strongly associated

> with the risk for ischemic stroke after multivariable

> adjustment, " Dr. Kurth and colleagues write. In fact,

> when these factors were excluded, a significant

> relationship between ischemic stroke and HDL-C

> emerged, they point out.

>

> " The data of the randomized trials, the data of

> others, and our data strongly support the notion that

> lipids are a biologic risk factor for ischemic stroke

> and that avoiding unfavorable cholesterol levels may

> help to prevent ischemic stroke as recommended (by)

> the primary prevention guidelines of the American

> Heart Association/American Stroke Association, " the

> authors conclude. " Our results further underscore the

> importance of unfavorable lipid levels as risk factors

> for first ischemic stroke among apparently healthy

> individuals without prior vascular disease. "

>

> The study was supported by the National Heart, Lung,

> and Blood Institute and the National Cancer Institute

> in Bethesda, land, and grants from the W.

> Reynolds Foundation and the Leducq Foundation.

>

> Neurology. 2007;68:556-562.

>

> Clinical Context

>

> According to the current authors, trials of statin use

> have demonstrated protection against ischemic stroke

> among patients with existing strokes or TIAs, and some

> observational studies have found increasing risk for

> stroke with increasing total cholesterol levels. But

> while an association has been found between low HDL-C

> levels and ischemic stroke risk, the association of

> stroke with other lipid measures, such as LDL-C, is

> uncertain.

>

> This is a longitudinal cohort study within the Women's

> Health Study of health professionals to determine the

> value of lipid parameters as predictors of stroke risk

> in women who were healthy at baseline and who were

> followed up for a mean of 11 years.

>

> Study Highlights

>

> Included were 27,937 women who were registered health

> professionals in the United States or Puerto Rico aged

> 45 years or older without cardiovascular disease,

> cancer, or major illness, who were subsequently

> randomly assigned to aspirin, vitamin E, both, or

> neither, and who had blood drawn at baseline for

> cholesterol measurements (lipid panel).

> Women were sent questionnaires twice in the first year

> and yearly thereafter asking about study outcomes,

> including stroke.

> Participants who reported stroke had their medical

> records reviewed for confirmation of diagnosis.

> Nonfatal stroke was defined as a new focal neurologic

> deficit over 24 hours in duration.

> Fatal stroke was defined by evidence of

> cerebrovascular mechanism obtained from autopsy,

> medical records, family members, or diagnostic tests.

> The type of stroke (ischemic vs hemorrhagic) was

> determined by results of diagnostic tests.

> The association between cholesterol measures and

> stroke was determined by age (younger than 55, 55 to

> 64, 65 years and older), history of hypertension, BMI,

> smoking status, current menopausal status, and aspirin

> assignment.

> Mean age was 55 years, 95% were white, and 13% had

> vocational nursing training.

> Women in the lowest quintile of total cholesterol had

> levels less than 179 mg/dL, and those in the highest

> quintile had levels higher than 244 mg/dL.

> Those in the highest quintile had higher BMI, blood

> pressure (BP), and were more likely to have

> hypertension, diabetes, or migraine and to smoke.

> During 11 years of follow-up (307,769 person years), a

> total of 282 ischemic strokes were reported.

> Compared with women in the lowest quintile, those in

> the highest quintile had adjusted hazard ratios (HRs)

> of ischemic stroke of 2.27 for total cholesterol, 1.74

> for LDL-C, 0.78 for HDL-C, 1.65 for total to HDL-C

> ratio, and 2.45 for non-HDL-C.

> Additional adjustment for systolic BP and

> antihypertensive or aspirin use attenuated the

> association, but the association remained strong.

> For every 1-mmol/dL (38.7-mg/dL) increase in

> cholesterol, the adjusted HR was 1.17 for total

> cholesterol, 1.15 for LDL-C, 0.91 for HDL-C, and 1.19

> for non-HDL-C.

> The best predictive model for ischemic stroke

> incorporated non-HDL-C followed by the model that

> included total cholesterol and one that included

> LDL-C.

> Thus, the strongest predictor of stroke risk among

> cholesterol measures was non-HDL-C followed by total

> cholesterol followed by LDL-C.

> The association between total cholesterol and ischemic

> stroke was not modified by age, smoking status, BMI,

> history of hypertension, or aspirin assignment but was

> modified by current postmenopausal hormone use.

>

> Women who used postmenopausal hormones did not show

> the increased risk for ischemic stroke with increasing

> total cholesterol.

> The authors noted that other studies have also

> identified non-HDL-C as a strong predictor of coronary

> and overall cardiovascular disease.

> Pearls for Practice

>

> In healthy women, total, HDL-C, non-HDL-C, and LDL-C

> levels are all predictors of ischemic stroke risk

> during 11 years of follow-up.

> The strongest cholesterol predictor of ischemic stroke

> risk for women is non-HDL-C followed by total

> cholesterol followed by LDL-C.

>

>

[Guest guest]

Just another view on his important topic.

Ralph Giarnella MD

Southington Ct USA

*************************

Hyperlipidemia Management Depends on the Details

Karla Harby

April 16, 2007 (Seattle) — Simple hypercholesterolemia

is different from combined hyperlipidemia, which is

associated with obesity and metabolic syndrome, and

the two conditions respond somewhat differently to

different degrees of dietary fat modification and

restriction. But based on a review of the research to

date, restricting total fat intake to less than 25% of

calories " doesn't serve anybody well, " H.

Knopp, MD, professor of medicine at the University of

Washington in Seattle, told Medscape. He presented his

findings here at the annual meeting and clinical

congress of the American Association of Clinical

Endocrinologists.

Combined hyperlipidemia is defined as increased

low-density lipoprotein (LDL) cholesterol, decreased

high-density lipoprotein (HDL) cholesterol, and

increased triglyceride levels.

The National Cholesterol Education Program (NCEP) ATP

III Guidelines currently advocate a fat intake of 25%

to 35% of total calories. In ongoing work, Dr. Knopp

is studying the efficacy of a diet that is 40% fat in

people with combined hyperlipidemia. " A higher-fat

diet for obese people might be better, " he said. But

for lean people with simple hypercholesterolemia,

dietary management alone might be effective.

Dr. Knopp also presented his findings from a recent

pilot study in 20 subjects with simple

hypercholesterolemia; 10 subjects received ezetimibe

plus coleseveiam hydrochloride, while 10 received

ezetimibe alone (Metabolism. Dec

2006;55(12):1697-1703). After 12 weeks, no difference

was observed between the two groups. Dr. Knopp told

Medscape that he was surprised by his findings. " I

thought the combination would be better than one

alone, " he said.

Extremely low fat diets fail to show a benefit because

below a certain threshold, the body will manufacture

its own saturated fat, Dr. Knopp explained. He

described both published and unpublished research.

The diet-heart hypothesis was tested early in the

Finnish Mental Hospital Study, a well-controlled,

12-year comparison published in The Lancet in1972 (Oct

21, 1972;2(7782):835-838). The researchers substituted

skim milk and soy for saturated fats in these captive

subjects, and observed " a major lowering in

cholesterol " of about 30 mg/dL, and heart disease

incidence dropped by one-half to two-thirds, Dr. Knopp

said. But early attempts to replicate this

" Mediterranean diet " by the National Cancer Institute

were stalled by methodological hurdles. " So the idea

of substituting polyunsaturated fats for saturated

fats went out the window, at least in the United

States, " Dr. Knopp said.

Instead, replacing fat with carbohydrate became

popular in the 1980s. But Dr. Knopp cited studies

showing that high carbohydrate diets raise

triglyceride levels and fail to show any weight-loss

advantage. Animal studies suggest that when dietary

fat intake falls below 25% of total calories, the

liver compensates by lipid hypersecretion. " The main

message here is that the typical low-fat diet does not

appear effective in combined hyperlipidemia, " Dr.

Knopp said.

The high-fat, Atkins-type diet is similarly

ineffective, Dr. Knopp said. This diet tends to

increase LDL cholesterol, even when people are

actively losing weight. He added that researchers have

yet to report on this diet's cardiovascular outcomes.

" This is someone who has enormous historical knowledge

in this field, which is terribly important because

managing lipids and their effects on health is a

long-term study, " Yank Coble, MD, distinguished

professor and director of the Center for Global Health

and Medical Diplomacy at the University of North

Florida in ville, and moderator of the session,

told Medscape. He noted that negative studies often

fail to get published, and that regrettably, diet

strategies become popular among the public even with

" no substance " behind them.

Dr. Coble said that physicians should take into

account the individual nature of these conditions and

should emphasize moderate diet and aerobic exercise

for patients with combined hyperlipidemia. He also

said he found Dr. Knopp's research on ezetimibe and

colesevelam HCl " pretty convincing, " and that a

one-drug approach is likely to have fewer adverse

effects than a combination therapy.

The study was independently funded. The authors report

no relevant financial relationships.

AACE 16th Annual Meeting and Clinical Congress:

General Session. Presented April 15, 2007.