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High cholesterol one risk factor among many for heart disease
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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: We suddenly became responsible for our 90-year-old neighbor after the death of his wife. He complained of poor sleep and backache in the morning. 

  When his newly assigned nurse/caregiver changed the bedding, she discovered that the mattress was permanently sagging. When we questioned him, he said that in 40 years of marriage, he and his wife had never bought a new mattress, and probably had used the one he had before marriage.

  We immediately replaced the mattress, and his sleep problems and backaches were gone! 

  Perhaps that is the case in a recent column of yours about an 80-year-old man with back pain. -- F.P.

  ANSWER: You may be right, and I appreciate your writing. Unfortunately, I do see many people with persistent back pain despite recently buying a new mattress.