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My Thoughts on Statins (From a Heart Surgeon) — Transcript

by Jeremy London, MD · 2,038 words · 352 segments · language en · Watch on YouTube

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0:00As a heart surgeon, how do I feel about
0:02cholesterol and statins? Sometimes you
0:05just have to address the big pink
0:07elephant in the room, and I think it's
0:09important that I'm very clear on what my
0:12position is. First of all, cholesterol
0:15is not the enemy.
0:17Cholesterol is essential for life. If we
0:21had zero cholesterol, we couldn't
0:23survive. Cholesterol is so important for
0:26cell membranes, hormones,
0:28neurotransmitters,
0:30and all of the cells in our body make
0:32their own cholesterol. So, cholesterol
0:35is an incredibly important part of our
0:38overall physiology. That being said,
0:41cholesterol has to be wrapped or
0:42transported
0:44in a coating because it can't be
0:46transported by itself through the
0:49bloodstream. And what it's transported
0:51in is something called a lipoprotein.
0:54You've probably heard of apolipoprotein
0:57B or apoB or lipoprotein little a,
1:00Lp(a).
1:02This is what allows the cholesterol to
1:04be transported through the bloodstream.
1:07And it's this coating, it's the trucks
1:11that the cholesterol is actually
1:12transported in, that enable the
1:14cholesterol molecule to penetrate the
1:17vessel wall and actually start the
1:20process of atherosclerosis.
1:22So, it's not the cholesterol itself,
1:24it's this lipoprotein layer.
1:27And we know that the more atherogenic or
1:30dangerous lipoprotein particles that you
1:33have in your bloodstream, the higher
1:35your risk of heart attack and stroke.
1:38And this is truly why two people can
1:41have the same LDL-C or total LDL levels
1:46and have a different risk profile
1:49because it's the number of trucks that
1:51that same amount of cholesterol is being
1:53carried in that truly determines
1:57how much risk the patient has. In other
1:59words, how many of these particles are
2:02floating through your bloodstream that
2:04can actually penetrate the vessel wall.
2:07Now, this is not to say that ApoB and
2:09LDL-C are the only factors that go into
2:14creating atherogenic risk or your risk
2:17of of developing blockages in your
2:20arteries because metabolic health is
2:22important, too. And here's why. There's
2:24really two components to atherosclerotic
2:28disease. And that is having elements in
2:32your bloodstream that can penetrate the
2:35vessel wall, like ApoB, and the
2:38vulnerability
2:40or the health of that inner lining of
2:44the blood vessel. In other words, how
2:46healthy is this lining to be able to
2:49protect your body from penetration? And
2:52that's where metabolic health becomes
2:55important. In addition, metabolic health
2:59weaves directly back into the creation
3:03of the atherogenic particles because
3:06high blood sugars
3:08lead to high triglycerides. So, these
3:11things are all interrelated. It's not
3:14that cholesterol is the only reason.
3:16It's not that metabolic health or high
3:19blood pressure are the only reasons.
3:21It's all of these things together. And
3:23prioritizing
3:25what's most important in a given patient
3:28has to be individualized. Now, I believe
3:30that these things should be treated
3:32concurrently. In other words, remove the
3:35atherogenic or dangerous particles from
3:37the bloodstream and make that inner
3:40lining as healthy as durable as you
3:43possibly can to protect the vessel from
3:47invasion itself. Lifestyle choices are
3:50foundational. It's what everything else
3:53stands on. So, you want to start with
3:56diet, exercise, sleep, the basic
3:59components, but realize that diet and
4:04exercise for most people are only going
4:07to move the needle so much when it comes
4:10to your absolute LDLC and ApoB levels.
4:14When it comes to your overall metabolic
4:16health, it can have a more dramatic
4:19impact. Exercise to include aerobic
4:22training as well as strength training
4:24and appropriate recovery can make a huge
4:28difference for your overall blood
4:30sugars, fasting insulin levels, as well
4:33as help control blood pressure.
4:35So, we want to work both of these
4:37components concurrently when it comes to
4:40decreasing your overall risk of
4:43cardiovascular disease, but if we look
4:46at one particular component that has
4:48really been proven over the course of
4:50time, whether which it's with randomized
4:53control studies or with genetics, ApoB
4:57has clearly
4:59been shown to be causal for heart
5:01disease. Now, when we look at things
5:03like Mendelian genetics, in other words,
5:05people that won the genetic lottery that
5:07were born with very low cholesterol
5:10levels, very low ApoB levels, number
5:12one, they don't have any issue with
5:16their cell membranes, their hormones,
5:18their neurotransmitters. And you know
5:20what else they don't have?
5:22They don't have cardiovascular disease.
5:25So, we know from individuals that have
5:27low ApoB essentially from birth
5:32that they have a near zero risk of
5:35cardiovascular disease and no incidence
5:37of
5:39physiologic problems have been
5:42identified.
5:43So,
5:44let's say for a moment that you've done
5:47all of the work. You've done all the
5:49foundational work. You've got your diet
5:52teed up where you're eating adequate
5:54protein, your your micronutrients
5:57are appropriate because you've been
5:58prioritizing fruits and vegetables,
6:01you're taking in enough fiber. So, your
6:04calories are well balanced, your weight
6:07is well controlled, your visceral fat is
6:10is optimized, and your blood sugars and
6:13your insulin levels are very stabilized.
6:15But, your labs or your biomarkers
6:17continue to be
6:20less than optimal.
6:23Well, at this point, it's time to have a
6:26conversation about medications and
6:29realize
6:31medications are not a failure. In our
6:34current culture of maximize, maximize,
6:36maximize,
6:38many people feel like after they've done
6:40all this work and now they need
6:42medications that they failed someplace.
6:44And that's not the case at all because
6:47as I mentioned,
6:48the the lifestyle choices are the
6:50foundation that everything else stands
6:53on.
6:54So, especially metabolic health. Even
6:57though it can be really difficult to
6:58move the needle when it comes to LDL
7:00LDLC and ApoB,
7:02you can move the needle when it comes to
7:05your overall endothelial health or the
7:07health of that inner lining of the blood
7:09vessel by really prioritizing solid
7:12lifestyle decisions. So, what do you do
7:14next? Well, the first-line therapy is
7:17statins. I realize that statins have
7:19been demonized on social media and I
7:22understand why it can be so confusing.
7:24You know, Lipitor is the most commonly
7:29prescribed drug in the US.
7:32And I think there's a lot of suspicion
7:34around this and questions of of
7:37over-prescribing
7:39and inappropriate use. And I'm sure
7:41there is some of that.
7:44But, what you have to realize is that we
7:46know from years of high-quality
7:49randomized studies
7:52that by lowering apoB with statins, not
7:55only do we decrease the number, but we
7:58also decrease the incidence of heart
8:00attack and stroke. And this is time and
8:03time and time again. Now, do statins
8:06have side effects?
8:08All medications have some sort of side
8:10effect profile. And there's no doubt
8:13that the side effects from
8:16statins are in fact real in some
8:19individuals as far as muscle weakness,
8:23muscle pain, elevation of blood sugars
8:26if you already have a tendency towards
8:28prediabetes, it absolutely can can push
8:31you over the edge. But, what you need to
8:32realize is statins are not the only
8:36option.
8:37There are multiple other categories of
8:41medications on the market that can be
8:44utilized, and just because you have side
8:46effects from a medication, that's not a
8:49reason to throw the baby out with the
8:51bathwater.
8:52You don't want to just not deal with
8:55your with the risk of cardiovascular
8:58disease because of a side effect that
9:01you may be experiencing. You want to
9:02explore other options like PCSK9
9:05inhibitors that actually increase the
9:08amount of receptors on the liver that
9:11pull
9:13the apoB out of the bloodstream, or
9:16bempedoic acid, ezetimibe that has this
9:19really beautiful mechanism where
9:22it actually causes you to excrete more
9:25cholesterol through your GI tract.
9:27Cholesterol is a very important part of
9:29our digestive enzymes and juices. So, by
9:32excreting more, the liver says, "Wait a
9:34minute. I I to send more cholesterol to
9:37the GI tract for digestion, so it up
9:40regulates these receptors and it pulls
9:43more apoB out of the bloodstream and
9:47sends it to the GI tract to be utilized
9:51for digestion. This lowers the number of
9:54atherogenic particles that are floating
9:56in your bloodstream. So,
9:58there's a lot of different categories
10:00here to choose from and this is a
10:01conversation
10:03that you need to have with your health
10:04care professional. So, where do I stand
10:07on cholesterol and statins in
10:10particular? Well,
10:11cholesterol is essential.
10:14We need a certain amount of cholesterol
10:16in our bodies and every cell in our body
10:19makes its own cholesterol, uh
10:21specifically the brain.
10:24And so,
10:26we know that this is an essential
10:27component for our overall physiology,
10:31but statins
10:33and other medications
10:35can decrease your risk of heart attack
10:37and stroke without
10:40creating significant risk on the other
10:43side and that includes dementia.
10:46There's been a recent study that just
10:47came out in the last couple weeks that
10:49showed that in in individuals that are
10:5270
10:5370 years old or older that have a
10:56history of cardiovascular disease and on
10:58statins for long periods of time, there
11:00was no increase
11:02in dementia.
11:04The cells in our brain make their own
11:06cholesterol and many of these drugs
11:08don't even cross the blood-brain
11:10barrier. It's a matter of choosing the
11:12right drug for you. In the end, this is
11:15all a game of probability. It's about
11:18maximizing benefit and minimizing your
11:22risk.
11:24Where do you start
11:26foundationally?
11:28Lifestyle choices first.
11:31Be mindful of your diet,
11:33move your body every day, and be certain
11:37that you're getting enough rest and
11:39recovery so your body can repair.
11:43Once you've done these things, it's time
11:45to recheck your numbers. Don't just rely
11:48on the fact that you're making the
11:50effort. You need objective data
11:53that you're actually decreasing your
11:55risk. Recheck your labs.
11:58If they're still abnormal, this is an
12:00opportunity to have a conversation with
12:02your health care professional and decide
12:04what is going to be best for you.
12:07Remember that our bodies are very
12:10complicated
12:11and complex.
12:14And it's not just one factor
12:17that causes a certain disease process
12:20most of the time, and that's
12:21particularly true when it comes to the
12:24atherosclerosis.
12:26We know that both a high level of apoB,
12:30having those particles that can
12:31penetrate the wall of the vessel and
12:34start the process of atherosclerosis, is
12:37very, very important and that it's
12:38causal for heart attack and stroke, but
12:41we also know that the health and
12:44durability of the lining of that blood
12:46vessel is also critical. So, metabolic
12:50health is also an incredibly important
12:53component when it comes to decreasing
12:55our overall risk.
12:58And all of these things can be done at
13:00one time. You don't have to focus on one
13:04or the other. Focus on both. Why not?
13:08Because the goal here
13:10is to to start and start early because
13:14we know that atherosclerosis is a
13:17disease that is directly related to the
13:20amount of time
13:23that the vessel wall is exposed
13:26to the things
13:28that can either penetrate it or make it
13:30weak.
13:32So, the sooner you get started, the
13:34sooner you address these things, the
13:37sooner you can start to decrease your
13:39risk of heart attack and stroke. We want
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