 Now I'd like to introduce Dr. Felton. Dr. Felton, I'm going to repeat this. I know most of you have probably already heard it. He completed his undergrad degree from the Illinois Institute of Technology in Chicago, completed medical school at the University of Wisconsin, completed his residency and fellowship at Loyola University Medical Center in Chicago, and that is where he and I met over a patient having chest pain. After completing his training, Dr. Felton came to Saginaw where he practiced medicine at St. Mary and Covenant, and he has been here at MidMichigan Health for the past 10 years. Will you help me welcome Dr. Felton? Thank you, Jennifer. Is this, can you hear me, or do I need to speak? Can you hear OK? All right, so I'm going to make this informal. As you know, I like questions. So I like to, you can interrupt me, raise your hand. If you see something at the time you have a question, that's perfectly OK. Today I want to have fun. Last month was a lot of information. This month is going to be more information, but also some fun. So let's start with fun. Who knows what this picture is? Everybody knows this is the Mona Lisa, right? Madonna Lisa Marie Diajardani, it was painted by who? The emarted Da Vinci, right, in the late 1400s. Go to the next slide. What are these? Bad eyes. Those are bad eyes. Probably the vision's OK, but these yellow deposits are cholesterol deposits. And those cholesterol deposits are called xanthalasma. And if you have xanthalasma, very high likelihood of having very high cholesterol levels. So let's go back and look at this. See here? In her left side on the nasal bridge, Da Vinci painted this in the picture. Probably the first case ever of documented xanthalasma, although we don't know that for sure. We don't know what was in his thought process. He's not going to add this. She was considered beautiful young woman. And you're not going to add a xanthalasma unless she really has it. Yet nobody defined that term until the 1800s in a publication called The Atlas of Skin Disorders. And then in 1985, the Nobel Peace Prize was awarded to Goldstein and Brown, who elucidated the path. We have these people with very high cholesterol levels called heterozygous, familial hyperlipidema, or homozygous, who often have these deposits. So this may be the first case ever documented xanthalasma 500 years ago. Pretty interesting. We don't know that, but that's sort of the thought in the medical literature. So if you go forward, this is not good. If you have that amount of deposits, your cholesterol is probably 300. And your LDL cholesterol is probably 200. Let's go further. If you see this, what do you see this other than bloodshot eyes? But look at this white ring. This white ring is called arcus carnelis. It's a white ring of cholesterol deposit around the eye. Now as you age, if you're 80s, 90s, you may naturally have a slight white ring. But when you're 20, 30, 40, 50, if I'm looking at you and in five seconds I see a xanthalasma and an arcus, you better believe I'm checking your thyroid and checking your lipids. Very interesting. Let's go further. What is this? Oh my goodness, this patient, whether they have scabies or bedbugs, no. They have tuberous xanthomas. Their triglyceride levels are so high, they're popping out with a skin disorder. Now, six years ago in Pigeon Clinic, I see a young guy in his 20s. He's a couch potato. Doesn't exercise at all. Drinks three bottles of Mountain Dew every single day. This is a true story. He eats fast food McDonald's every day. His body mass index is over 50. I look at him and his skin is like this. His skin has erupted. These pulsatiles, these eruptions of cholesterol deposits. His triglyceride level was over 4,000. His triglyceride, so I had a heart to heart talk and said you either change things or you're dead in your 30s, later in your 30s. He did change things and the exercise lost weight did much better and his triglycerides dropped tremendously. Let's go back to 1987, 1987, Loyola, Chicago, young guy, 20s, has a mini stroke. You don't have mini strokes in your 20s unless there's really interesting problems hole in your heart, embolization up to the brain. He didn't have that. So he said, you know, we better draw blood. We stick his arm, at that time, the interns meet. The low level on the totem pole is drawing the own blood. Pull his blood back and it's white. The blood is milky white, thick. His triglyceride levels were 20,000. 20,000, normal is under 160. He had a very rare type five hyper triglyceride, he was at risk for major stroke and death. So he actually had to have his plasma exchanged and plasma freezes, something rarely done. There's only about 600 people in the country who have this heterozygous, or this homozygous familial hyperlipidemia with extremely high levels that we need to do very advanced therapies. Today, I'm talking about you and me sitting here in this group with cholesterol that may be normal, may be slightly elevated, may be moderately elevated, not to these extents. Now let's look at, this is something I see, maybe once every six months, this is not good. This is a patient who probably had a heart cap or had some intervention and scraped plaque off the aorta. In four days later, he looks and says, I'm, something's going on doc, my toes are discolored. These are cholesterol embolization pla, these are from cholesterol plaques in the aorta that have embolized to the feet. There is no good therapy for this, you hope that they're toes that don't get necrotic toes in an amputation. But this is serious. So cholesterol disorders are not to take lightly. Even cholesterol, you can have this even with cholesterol level of 210. If you have plaques in the aorta and we're manipulating the aorta to do invasive procedures. So those are just some slides that I wanted to show you. You know, these are real, we see these in clinical practice. Those anthalasmas though I see fairly frequently. Now, just a couple of review slides. Some of these, these first 10 slides we won't over last time, but I want you to refresh your memory. Pathophysiology of acute coronary syndrome. Acute coronary syndrome is unstable angina. You come in now with nuances of pain at rest. Or you have non-ST elevation of my elevated troponin suggestive of heart damage. Or the really serious one, the ST elevation of my when the artery is completely occluded and you get rushed off to the cath lab. So pathophysiology of the acute coronary syndrome is rupture of these plaques. Notice this plaque is not a 99% stenosis, 20 to 30. And the plaque ruptures, clot forms, boom. Acute coronary syndrome. So even 20 and 30% plaques in your arteries are dangerous. It's the 90% plaque you actually may be lucky that causes angina that comes in and warrants a workup. We find it, we put a stent and you go on your way. These 20 and 30s that are not treated and you're not on lipid lowering, those are the deadly plaques which can cause the majority of heart attacks. I already talked last time the incidence of myocardial infarction in the US is high. It remains high. 500,000 infarcts, new heart attacks every year. 190 recurrent heart attacks every year means one every 44 seconds and one person dies every four minutes in the United States from a heart attack. We talked about good and bad cholesterol, HDL cholesterol, heavenly, the higher the HDL, the better off you are. We talked about familial groups that have extremely high HDLs and live healthy lives into their 90s. And then we talked about LDL and that's what we're gonna focus on again today. What can we do other than these quote unquote poisons which I prescribe to you? Are there other things you can take to lower cholesterol? I wanna emphasize again, I showed you this, there is overwhelming evidence that LDL cholesterol must be lowered. And I don't care, the preferred way to lower it is to lose the 30 pounds exercise and eat healthy. That is what I strive for everybody to do. Doing that you can often see your LDL drop 11 to 25%. So if your LDL is 90 and I want it to 70, you can often do that with lifestyle. We talked about how low is too low and I said we don't know, the lower the better. If your LDL is 130 and you had a heart attack, it's too high. If your LDL is 60 and you had a heart attack, it's too high. Years ago we told people LDL of 190 was normal. Now we laugh at that and say that's ridiculous, you want an LDL below 100. So there's no level that's too low. If you're diabetic and you're having events and your LDL cholesterol is at a certain number, get it lower if you can. Talk to the knock. And why is that? Because I don't care where your LDL is, whether it's 90 or whether it's 60, continue lower you go, the relative risk for coronary events is lower. So if the doctor says, whoa, your LDL is 50, let's cut back on your medicine, say okay, let's try to do that, let's watch it, but do you think that's a good idea? So as of now we don't know how low to drop the LDL. We do know studies show safety of extremely low LDL levels, studies we participated here in mid-Michigan, where we were getting LDL levels down to 20s and 25, and data monitoring safety board through Duke and Harvard continued to monitor and said no increase incidents of adverse events, continue to push the LDL because the patients were doing better. We also know that HDL is beneficial. And the higher the HDL, the better off you are. So for every 10 milligram increase in your HDL, your heart disease risk is reduced 50%. Did you hear that? For every 10 milligram increase, so if your HDL is 30 and you go to 40, 50% less chance of having a heart event in the next year, tremendous. Problem is we don't have good medicines for HDL. We've tried and tried and tried, and you think that the medicine, medicine raises HDL and then the risk of death is higher. What is that all about? I just told you HDL is good. We put you on a medicine and you have a higher instance of death even though we increase your HDL to 100 because the medicines had other side effects which we didn't anticipate. Medicines increased the kidney production of hormones which were dangerous, which raised the blood pressure, which caused strokes and death from another problem. So just because a drug has an event that says it lowers LDL or it raises HDL or just because a vitamin claims that it's good because of this, if you don't test it in a randomized study, you have no idea what's gonna happen when you take it. So every drug we've tested so far for HDL has not been found to have event reduction. We've found drugs, the majority have not been found to have event reduction. We'll talk about that in a bit. But as of today, there are no great meds on the market for increasing HDL which also have beneficial effects. So why do we even need, how can you even have high cholesterol if you eat healthy? So if you look at this look doc, I'm a penguin. All I do is swim and eat fish. How on earth do I end up with high cholesterol? Because 85% of our cholesterol is not taken in the diet. 85% comes from the liver. So you can eat extremely healthy. You can be my patient who is a marathon runner and a vegetarian and still had a heart attack. So diet's important. But even everything you do at the diet, you have to be conscious that your liver is churning out eight times what you take in what's considered a healthy diet. So we need to do something as well with cholesterol manufacture in our body. So why does the body need cholesterol? Cholesterol's important for vitamin D. You need vitamin helps make vitamin D which is very essential. It makes hormones. It makes sex hormones, estrogen, testosterone. You need cholesterol to control your cell membranes. Your cells would fall apart without it. It controls, it coats the nerves, particularly nerves in the spinal column and the brain. It makes bile salts. You need those for absorption and food digestion. It helps to absorb all the fat soluble vitamins A, D, K, E. And it acts as an anti-inflammatory agent in the body. Helps repair damage that oxidize, that oxidation does and very important. So we need cholesterol. Now when we look at risks, I showed this slide and now we're just finishing the old slides. If you look at all the risks, population, a tributal risk, meaning if you can change anything, smoking, of course very important to stop, eating more fruits, vegetables, exercising, alcohol and moderation. One drink for a female, two for a male. All of these things control the blood pressure diabetes. The biggest bang for the buck is controlling the cholesterol. And it's also one of the easiest. You know, I hate to say it, but it's not easier to control your cholesterol than it is to get a body. My wife just said ideal body mass index is 24. Good luck with that. I mean, that is a challenge. If we look around, you know, I don't have a BMI of 24. It's very hard to achieve. It's not real hard to achieve the cholesterol with what we have available. So let's go on to some new slides. Unwavering benefit of statin. Some of you are gonna sit here today and say, hmm, he just won't give it up. He just keeps talking about these medicines and I've tried them and I can't take them. And I know there are people who can't take them. We have alternatives. But nothing should dissuade clinicians from using statins in high risk patients, particularly look at the last line, particularly in diabetics. So the statins, and why do I say that? Because we have overwhelming evidence now since 1984. No matter what study you run, randomized study with statins in secondary prevention, these are patients who already have disease. No matter what, every single study keeps showing a benefit. Whether it's statin versus placebo or new statin versus the old statins, every single one keeps showing a benefit on event reduction, events or cardiovascular events, death, stroke, and heart attack. Primary prevention. What if you're 40 years old, you have no heart problem but your cholesterol is very high. Should you be on a statin? It depends. That depends on your risks, on your genetic, on your history. And if you see those who were put on stands for primary prevention, same thing again, lower risks. So in this room we're talking about secondary prevention. You're here because you are as loved one has heart disease. So it's already there. There's more benefit for treating in secondary prevention than primary prevention. So I have high cholesterol. I've told you this before. I eat pretty healthy. Jennifer forces me to eat healthy. And I could not lower mine. So I would be primary prevention. I don't have heart disease. So if I take a statin, it's to prevent it. And when I was 30, I'm not gonna take a statin. I'm 30, I'm a pretty healthy guy. It's not even in my mind to take a statin. When I was 40, I knew the evidence and I said, hmm, you know, it's probably time for me to take a statin. I didn't. I waited until I was about 48. And then I started Crestor and I've been pretty faithful with it since. Because you always have to weigh risk versus benefit. And if you're taking a statin at age 30 for the next 60 years, there may be more risk than taking a statin at age 60. So when we prescribe these medicines, again, risk versus benefit. We already know the benefits. It's overwhelming. So let's talk today about a little bit of the risk. This is a study done by my nurse who's leaving me as of the next week. She's leaving me after, I've had two nurses here in 20 years. Both of them were outstanding. Both of them have gone on for higher education and she's getting her master's in nursing. And to do that, you have to do a master's thesis. And she did a survey of cardiology patients, patients that come to see me. And they sit in the waiting room and they fill out a survey and say, what are you able to identify risk factors? High cholesterol, smoking, hypertension, family history, obesity, and diabetes. Out of these, which of these are a risk for heart disease? Almost everybody knew high cholesterol and smoking, high hypertension, physical inactivity, obesity, diabetics. Only 60% of people in a heart clinic knew that diabetes was a significant risk for heart disease. And I found that shocking. We're not doing a good job then in the country educating people about diabetes. And I'm talking adult onset diabetes, juvenile onset, insulin as a teenager, through like whole another ball game, much higher risk. I'm talking adult onset diabetes. So let's talk about diabetes a bit, statistics. It's an all time high in the US. In 1958, 1% of the population had it. In 2019, 9.5% of the population has it. 30 million adults aged 18 and over. Increase of diabetes increases with age. It's natural as you age, the risk goes up. So if you're over 65, 25% of adults will have diabetes. Risk for developing is higher when you have excess body fat, high blood pressure, high cholesterol, family history, age we talked about, or gestational diabetes. So if you're a female and during pregnancy, you are diabetic and then you're not. Later in life, your risk is slightly higher. From 1998 to 2008, the incidence increased from 15 to 25%. More people die from diabetes each year than die from AIDS and breast cancer combined. And it's the seventh leading cause of death in the US. If you have diabetes, how do you die? You don't really die quote unquote of diabetes. You die of the complications of diabetes, which includes stroke, heart attack, and kidney failure. More than one quarter of all Americans with diabetes have diabetic retinopathy, meaning their eyes, their vision goes. They develop problems on the retina and eventually the vision goes. 50,000 Americans every year will lose their kidneys because of diabetes and will be on dialysis. Diabetes causes 75,000 limb amputations a year. Nothing we can do, we can't revascularize anymore. Boom, chop off the leg. In 2012, the productivity loss for decreased performance due to diabetes was 113 million days of productivity accounting for a staggering $21 billion. And the cost of diabetes overall cost for medical care is a third of a trillion dollars just for diabetes. It's why cardiologists, you can't hire enough of us, we can't keep it up. But the good news, so diabetes is serious, take it seriously. Check what your A1C, doc, why do you think that it's good to have an A1C of eight when Dr. Felton and others say seven? What can I do? What can I take? How can I lower my risk? Stattons. Stattons and development of diabetes. So there is some controversy. People come to me all the time in the office and say, doctor, I heard that if you put me on a cholesterol medicine, I'm going to develop diabetes. Wow, I just showed you these horrendous statistics about diabetes and now you're telling me if I put you on a medicine, it could cause me to develop diabetes, what is up with that? Is that true? Well, not exactly true, but if you look at this, on this side of the curve, on this side of the straight line, these are all major United's international studies showing the benefit of statins. But if you look at those on statins had a propensity to have a slightly higher risk of diabetes. It was not statistically significant, but there was a slightly higher risk. Every single one of the studies except the West of Scotland on pravastatin. The trend was those who were on the statin seemed to have a slightly higher incidence of diabetes. So did it cause it? So no, we don't think it did cause it. Could it nudge you into diabetes? Think of what patients are in these studies. These are the older patients with heart disease, with the central obesity, they're pre-selected. The incidence of diabetes is slightly higher, but we still think there may be some effect. So if you have pre-diabetes and are on a statin, you wanna follow it closely. So the consensus among experts is that statins do not cause diabetes, but if that's the path the patients are already on, it may increase, it may tip you in that direction. So these patients were already close to the entry point of diabetes, just given the fact that they have heart disease and they're enrolled in the study and they're on statins. So it's something to keep in mind. So patients with risk factors need education. Of course we're gonna use a statin, but they need to understand about the metabolic syndrome. That's the central obesity. I'm heavy-docked, but it's around my abdomen. It's generally more in men. They have the low HDL cholesterol, the high LDL cholesterol, high blood pressure, and pre-diabetes or diabetes or glucose intolerance. So be aware, be aware of weight, age, and pre-diabetes. And if you have that focus on risk factor reduction, statins prevent more cardiac events in diabetics than a number of cases of diabetes in the country. So has anybody here, I just wanna see a show of hands. Have you been concerned or have you heard that statins do cause diabetes? Okay, so it's out there in the literature and we do think, like I said, there seems to be a slight trend, but it's not necessarily a cause and effect. Some of those patients are already sort of predestined for it. I was gonna ask, do the studies correct at all for the risk factors? They do. So these are not poorly run studies. These, excellent question. If you just look at a trend, well, okay, but if you correct for the risk factors, if you screen out, if you look at everyone with the same body mass index, the same triglyceride, the same everything, and then those on the statin versus not, still a slight trend. So went, but when you know the statin is lowering your risk for a heart attack, death or stroke by 25 to 30%, and the trend towards glucose intolerance is zero point, you know, so much percent, the bang for the buck is there. But I thought maybe more here would have heard about that because it does seem to be more in the literature and some patients do ask me about that. So the take home message with statins and diabetes, irrespective of people's real fear or imagined fear of how much this is going to affect glucose levels, we still must consider statins as the first line of therapy. You should see those patients several times a year and you'll say, doc, I can't even get in to see you. I call in, it's three months. How can you see me several times a year? You have to work with the mid-levels. You have to work with family care. You have to have your hemoglobin A1C monitored and pin the doctor down, say how do I get it to seven? Use hemoglobin A1C to tell patients that they're moving in the right or wrong direction. If you're pre-diabetes and you're on a statin but I see your A1C went from seven, eight to seven, three to seven, two, I'm really happy. And in fact, I'm gonna give you some really good news. And remember that patients are living longer. If you're pre-diabetic or slightly diabetic get 65 years of age, you still have a 20 plus year lifestyle expectancy. 20 years of untreated high cholesterol, you can forget the slightly higher sugar it's gonna catch up to you. So treat aggressively. Now, we talked about the benefits, fair and balanced here. I'm gonna talk about potential side effects. When you hear about statins, what do you think about? Do they cause diabetes? We talked about it probably not but it could tip you a little closer towards moving into that direction. Can they cause muscle pain and weakness? Absolutely, absolutely. The literature states anywhere from 6% to 14% in private, in practice I'd say it's at least 20%. Decrease cognitive function and memory. Doc, I heard that this is causing my mother to have Alzheimer's, dementia. She's losing her memory. She's 90 years old and you've had her on a statin. Now, did you cause my mother to lose her memory? Seriously, these are questions people are concerned because there's some data that says, do they cause, we're gonna talk about that briefly, liver inflammation, absolutely. Anywhere from 0.8% to 2.3% depending on the dose and the intensity of the statin. Can they cause kidney damage? This was interesting, I said kidney damage. Oh, rhabdomyolysis from muscle breakdown. The little lady that falls, breaks her hip, is laying on the floor for four days. The CPK, the muscle breaks down to 40,000. It affects the kidneys. Higher incidence of that on statins, very, very, very rare to cause kidney damage with statins. Decreased effectiveness of exercise. I see this sometimes in really pretty good athletes. Guys who ride their bikes for 30 miles a day and I have them on a stand for six months and they say, I can do it. But man, it's an extra effort to do it. And it's like, oh my, I don't wanna, I want you to ride your bike. I don't wanna put you on something that's hurting you. Is there anything naturally that we can do or something to help that? But those that are exercising and are maybe a little more physically trained and attuned to it, they may notice a slightly decreased exercise tolerance. Is this show with a slight decrease in the max heart rate? Because I know our exercise will hurt. Oh absolutely, but not from the statin. Usually that's from the other med we put you on the beta blocker. So the statin really is not gonna affect that heart rate, but you're right, if you're, you know, there's a couple subtle things you'll find with it. And I'm gonna talk about that in a bit. And then heart damage, heart damage. So I've never heard statins causing heart damage, but this is what's in the literature. And when you Google online, you get afraid. You're gonna be afraid to take a statin. There's actually stuff online. And I have rings of paper here that says if you take a statin, you're damaging your heart. Most ridiculous thing I've ever heard. So I actually did literature, and there's one article with 20 patients. And they did something called tissue doppler imaging and stroke volume imaging, obscure things. And found that tissue dopplers stayed the same on statins and stroke. And this other imaging was slightly reduced. And they said, if you're on a statin, you could see some slight subtle physiologic things. No difference in heart function, but then suddenly somebody on the internet says, oh my, if you take a statin, you could damage your heart. Totally ridiculous. So when you see that, if you're worried about it, talk to your doctor and say, you know, what is this real? Now, elderly patients, I have to be careful because my father-in-law is here and he is elderly, he's over 65. So elderly is generally in the literature, they're saying 65 years of age, which is getting scary to me because I'll be there in the next decade. But when we're talking statins and the elderly, they're using a cutoff of age 65, which as you know today 65, you can be in pretty good shape and can live another 30 years in a very good way. So the elderly and statin use, the elderly is a huge, there's a big difference between me starting a statin on a 65-year-old and starting it on a 95-year-old. So the elderly are a diverse population. There's diversity in age and mental status and health and economics, healthcare benefits, physical activity. There's a high degree of confusion and misperception regarding lipid management in the elderly. And the age of 60 is accepted by most developed countries as the definition of elderly in studies. And by the year 2030, the population is going to double by those over 65 years of age. So what is the average life expectancy if you're a 65-year-old female? What's the average? What do you, most people who are 65 and female, what can you expect them to live to? Absolutely, wow, we've got some sharp people. 86.6 is the life expectancy of a 65-year-old female. For a male, any idea? If you're 65, what's the average life expectancy? It is less, again, it's 84. Slightly less for men. But what did I just say? 20 more years on average. And if you really watch things, it can be much longer than that. So are we gonna give up and say, well, don't take a statin, you're gonna have more side effects, which you may as you age, but no. You potentially, the average is 20 years. You can live 30 more years. We better tackle this because as I showed you, as you age, the incidence of heart disease increases and cholesterol goes up. So old age equals increased risk. When you're 65, 70% of men and women already have heart disease. You may not know it, but it's a fact. In the United States, if you're 65, you have some form of heart disease. Hypertension, prior stroke, you probably have corneathorosclerosis, you may not know it, but trust me, it's there if I go in your artery and put a scope down and look, we're gonna find it. If you're 85% of men and women have cardiovascular disease when they're 80-year-older. So it's critically important to treat people as they age. And again, there's a big difference between 65 and 90. I have a 95-year-old who I saw today. And I was up in pigeon today, smart lady, completely with it mentally. The off, I was reading her the note from one of my partners, this extremely bright, vigorous and healthy 95-year-old female and she's laughing and thought it was so wonderful, looking younger than her stated age. This woman needs a statin. Am I gonna stop a statin on her when she has had a heart attack and heart disease and she's doing extremely well? No way, because I know I'm benefiting her six, just six months of use. So when we look at considerations in the elderly, be aware, you may wanna use a reduced dose. Be aware of polypharmacy. There's, be careful when you're using four different medicines for one problem. And be careful with statins because they do interact with other medicines and I'm gonna talk about that briefly. Also, the cost can be overwhelming in the elderly. Why would I put somebody on a brand name drug that has a copay of $150 a month when they can go to Myers and get the medicine free and it does the same thing? So I always get a little bit disturbed with that, but be careful when the physician is treating the elderly. If you say, doc, I can't afford this, I'm not really taking my medicine and we can tell. If you're cholesterol, if your LDL is 70 and you come back and it's 150, you're not taking the medicine. Don't be embarrassed to say, well, I can't afford it. The copay, I have 15 meds, I'm in the bucket hole, there's no way. Talk to us, there's ways to get affordable medicine. So that's a consideration. And find the clinical practice. So if I'm deciding to start a patient over 75 on a statin, I'm gonna take all these things into account, benefit versus risk, their comorbidities, their life expectancy, quality of life issues, patient preference. If somebody does their homework and does their due diligence and understands and says, I just don't want it, I'm not going to argue. Okay, you're a smart person, you did your homework, but if they don't understand, it's our job as a physician to teach them like we're doing today and then you make the informed decision. So guidelines for statins in the elderly, you can see here, use high-intensity statins and certain patients, moderate and others, low-intensity. If you get up in age, consider that we're gonna start maybe with a lower-intensity statin or reduce the dose. Cognitive dysfunction, it's important to differentiate potential cause. So if somebody says, did my statin cause this or is it causing, I said, I have no way of knowing. The incidence is very, very low. It's much, much more likely that it's Alzheimer's or dementia or Parkinson's or inflammatory or vascular or metabolic or depression or diet than a statin. But if you're not sure and the family has concerns, stop it, see, you may have to stop it for months. Most of the time it's not the statin. So to summarize statin use in the elderly, it's critical to treat patients, the risk for stroke, hospitalization, death increases over 65, the guideline recommendations in clinical data support use of statins, and the goal is to improve quality of life. The goal's not necessarily always to live longer, it's to live with better quality of life. And if your quality of life is improved because you haven't had a stroke or a heart attack, yeah, consider it. Grapefruit juice. Now we're gonna go through a couple things and we're gonna do some fun things. That, I hear that grapefruit juice is no good. Can I drink it when I'm taking a statin? Depends. If you're on Simba statin, don't. Grapefruit juice inhibits the enzyme cytochrome P450, CYP3A4 and 5 in the liver. That enzyme is critical to break down, to metabolize statins. So if you drink a quart of grapefruit juice a day and you take Simba statin, the worst statin of all for drug interactions, it works. It's cheap, overwhelming data with it, but more drug interactions than anything with Simba statin. So because Simba statin is completely dependent on this liver enzyme, do not drink grapefruit juice if you're on Simba statin because you could inhibit its metabolism, levels increase, more risk of muscle problems. Interaction is worse with Simba statin. As I mentioned, a torva statin, you would need to drink one and a half liters a day really to have any effect. So we're talking grapefruit juice is probably overblown. We generally recommend not drink, you can have grapes, but not drinking grapefruit juice if you're on Simba statin and if you're on the others, it's okay in moderation. One of the keys to take away today is in moderation. Alcohol, in moderation, grapefruit juice, in moderation. Fat, in moderation, I'm gonna keep in moderation. So yes, you can have a glass of grapefruit juice if you're on any of the statins other than Simba statin. If you say, Doc, I love grapefruit juice, can you switch my statin from Zocor to another? Sure, no problem. I'm going to switch you to a medication that does more advertising. Okay, well, sure. Doc, what about this? I see it on TV, hmm. You do see it on TV, but I like this medicine better, and why is that? Because if you need to get your cholesterol down 100 points, most bang for the buck is a torvastatin or a razovastatin cruster. So I don't care what the marketing people say, I like to go with evidence-based medicine and I will try to pick the drug for you that you can afford and that's more efficacious for you than what marketers say. Now, this is an interesting slide because this is the rule of six. Remember the rule of six. If you're on 20 milligram, if you're on a dose of any statin and you double its dose, expect your LDL cholesterol to drop another 6%. So let's say you're on Lipitor 40 and your LDL is 160 and I want to get your LDL to 70. I double your Lipitor dose and your LDL is going to drop 9.6 points. It's gonna go to 150, not even close. So remember the rule of six. If we double your statin dose, you're gonna get your LDL down another 6%. Now, if you're at LDL of 75 and we want to get to 65, great. Or if you're on a weaker statin and we go to a more powerful, great. But if you have events and your LDL is 130 and you're on maximum dose of statins, something else has to give. You're not gonna get it there by doubling the statin. That's when we add two new meds, which I'll talk about briefly. So my heart will go on as long as I take Lipitor. Marketing is so fun because patients come and see these things and talk to me about it. So let's talk about cholesterol and muscle and cholesterol, drugs, poison, muscles. This is right off the internet. Don't take your cholesterol med. This is marketing. Don't take it. It's gonna poison your muscle. So 74,000 subjects in 35 randomized clinical trials. The in-incidence muscle problems is 15.4%. That's pretty high, you know? But the patients they randomize against who are taking a coated sugar pill, placebo, 18% incidence. Think about that. So 15% of those taking the active drug and those who thought they were taking the active drug but weren't, 18% of them had it. So the incidence is pretty similar between those taking a sugar pill and the active drug. But believe me, it is real. My elders is our real. And so what do we do? Coal Q10. Should we or shouldn't we? Comes up all the time. You see it on TV. Dr. Brand recommended number one is Coal Q, Quinoa Coal Q. I didn't even know what they recommend because doctors generally don't recommend a brand of Coal Q10. We don't even know if it works. But Coal Q10 is an antioxidant produced by the cholesterol biosynthetic pathway. Treatment with statins has been shown to decrease levels in the muscles. If your levels of Coal Q10 are diminished, you're more prone to muscle aches. So it makes sense to take Coal Q10 if you're having muscle problems. Unfortunately, no studies bear that out. There are no randomized clinical studies that tell us as physicians to put all your patients on Coal Q10. So you would ask a doc, you know, I come in and you don't tell me to take Coal Q10. I take it on my own, but you've never mentioned it to me. So I haven't mentioned it because I don't have data that it works. It seems like it's gonna work, but I can't prove it. But do I tell patients, sure. If they come in and say, boy, I'm just not sure. I'm aching a little bit. Is it the statin? I say, boy, I don't know. I'd really like you to continue it. Let's try Coal Q10 or let's try Magnesium first and see if that helps. So there's not, it makes sense, but we don't have overwhelming data. It's another one of those things that the FDA does not require any strict regulation. So if somebody comes in, they have a lot of muscle problems, confirm that there's appropriate indication. If the indication for statin is weak, get rid of it. Check the patient's thyroid level. Check their CPK and check vitamin D levels. Look for drug interactions. These are real guys. This, when you're on calcium blockers, when you're on amiodarone, be very, very careful. The worst drugs are right here. Right, look those up. Cause if you're on Simvastatin in particular, I always go back to Simvastatin. Nasty interactions with diltiazim, with any, with some of the antibiotics. Terrible interaction with phenylfibrates and gemfibrosol, antifungal, AIDS drugs, erythromycin. You go and they say, take a dose pack of this and they come back and oh my goodness, my muscles, what in the world happened? Oh yeah, you have a drug interaction. So be careful, especially in the 75, 80, 85, 90 year olds, these drug interactions are real. So when somebody comes in before I'm looking to stop, I'm like, oh, I didn't realize you're on cartizim. Who puts you on amiodarone? You know, always look for drug interactions, think about the thyroid, maybe give them a window and we'll talk about consider strategies such as reducing the dose, changing to a more mild statin, going on it once or twice a week, or stopping it for a period of a couple of weeks or a month or two and see if the symptoms improve and then launch a statin re-challenge. So 2017 recommendations for non-statins. I come in and patients will see me. Jen, I'm running a little long. What time? I'm not even through when we haven't done. I wanna get to the fun thing. So should I, yeah, I'll try to wrap it up in 10 minutes. I was hoping to wrap it up sooner. There are some fun things at the end, but non-statin therapy, the days guys of using three to four drugs for this are over. So patients come in and they're on niacin and phenol. I just saw it the other day. Doc, I need to see you. I'm seeing another guy and he has me on five drugs for my cholesterol and I feel like crap and my LDL is 20. I'm like, oh my goodness. You're on a statin, you're on niacin, you're on phenol fibrate, you're on zettia and you're on well-call. What in the world? Nobody tolerates that. And by the way, why would you even do that? There's no efficacy for these drugs. There's efficacy for statins. There's efficacy for zettia and there's efficacy for the PCSK9 inhibitors, rapatha and Pralluant. By efficacy I mean lower events. The other drugs do lower cholesterol and there's a role for very, very high triglyceride levels and taking some of the others. But be careful about polypharmacy. Question the doctor. Do I need to be on three or four meds or can you do it with one? The PCSK9 drugs are the injectables. We talked about them briefly last time. I'm a big fan of them. Some people mentioned they had had some side if I'm gonna skip through that because we mentioned. Can atherosclerosis be reversed? I hear this all the time. Doc, I was told I have a 50% blockage. Can I bring it down? Yes you can but you can go from a 50 to a 49.5% blockage. Does it mean anything? Well of course not. So we've done extensive studies. This is the GLAG off. I was actually part of this. These are a lot of these are run through Cleveland Clinic when we put a scope down inside of the artery and we look for plaque regression. And yes, we can reverse it a bit but from going to 50 to 48% is clinically insignificant. But what you do is you stabilize those plaques. So instead of being all fat, instead of being a real fatty plaque here that ruptures this is all fat and cholesterol you can stabilize it and make it all smooth muscle and fibroblast and that doesn't cause a heart attack. So don't think so much of plaque reversal. Think of plaque stabilization. Are high triglyceride levels associated with the greater risk? Yes they are. So if your triglyceride levels are, remember I said earlier that Hagia had 20,000. The other one had several thousand. We never see that. But if your triglycerides are 500 can inflame your pancreas. If they're 300, 400 higher risk for heart problems always emphasize or 99% of the time emphasize LDL first. And then if we need to, we'll add another therapy for the triglycerides. I remember I said earlier try to avoid combination therapy. So let's jump finally to vitamins, minerals and other supplements. Are these beneficial and lowering risk of cardiovascular disease? These are some things I took out the internet. Here's one that says nano health technology. You know buy this and drink this and you'll do better. Here's one cinnamon for high cholesterol. Turmeric, turmeric you hear about all the time. Is this helpful? This is only what $40 for the month. So it's only $500 for the one bottle. And some patients I've had bring in a hundred bottles and tell me doc is this good for me and I can't even navigate. I have no idea. I said what are these reactions? But think about super hot. This is cyan powder, omega three. We know omega three is helpful, at least natural. Advanced cholesterol support. I love this next one heart savior. I was thinking of marketing that myself but I'm not sure it's ethical. And then finally here we are joint syrup and pain with natural syrup. What about gululu? Never heard of that. But some of these are really interesting. So do vitamins and mineral supplements work? National Heart and Nutrition Exams Survey from 2011 to 12 shows that 30% of the US population takes a multivitamin or mineral supplement. Much higher in the elderly patient. I take one. I take a multiple because listen closely because I still take one even though you're gonna hear what I have to say. I take a multivitamin, a vitamin D. What do I take Jen? And vitamin C, okay. Now, let's look at the data though. Globally this will be a staggering $278 billion to the US economy by 2024 costs. NIH, National Institute of Health defines dietary supplements as greater than three vitamins or minerals daily. In a multivariant analysis quoted in circulation two million patients, 18 studies, 18 million person years of follow up were included in this analysis. This is hot off the press. Systemic review of all the published studies that are out there. And the study concluded that supplementation does not improve cardiovascular outcomes in the general population. Be careful, don't let people mislead you. I didn't say in the heart population. I said in the general population. This supports the present guidelines from the American College, American Heart, American Society of Intervention that recommend against the use of routine multivitamins. In subgroup analysis, when they look at, like you mentioned earlier, do they look at subgroups and do they take quality control? Yes, they did. And you know what they found? Increase fruit intake, increase vegetable intake and exercise. Those were independent variables. They could not find any other benefit of taking these supplements. Nutritional studies, nutritional studies have established that fruits and vegetables are a good source of all these vitamins and minerals and are associated with lower risk of stroke and heart disease with a strong dose response relationship. Report from Center for Disease Control revealed that 87% of the US population does not meet fruit and vegetable requirements or intakes. And that is, I wanna say, I thought I had it written here for you. Oh yeah, right here. Adults should eat one and a half to two cups of fruit a day and two to three cups of vegetables per day. The worst date for vegetable intake is West Virginia, only 6% meet the requirement. The best is Alaska. Seeing it's the best, only 12% meet the requirements. For vegetables, West Virginia's the worst. West Virginia has some problems with fruit, vegetables, smoking. It is unfortunately, Appalachia is a tough area. They're not doing real well and Washington, DC best for fruit intake. Consumption is lowest among men, younger people and people in poverty. And barriers to consumption of this include the higher class, limited availability, limited access and perceived lack of cooking preparation. The South side of Chicago has over 1.3 million people. 1.3 million on the South side. The South side of Chicago as until three years ago had no grocery store. Think about that. You had no jewel, no, on the South side, out south of the loop of Chicago when you go below about 22nd Street. These people had no, how can you get access? What are you gonna take, the bus 10 miles and go North where the money is and go shopping? You know what, the grocery stores there's no money to be made here. I'm not gonna go on the South side of Chicago. Where do they shop? The Monpa, the alcohol stores, the drive-in stores, the trans fat stores, nothing natural at all in that city. It's changed recently, but there's some real barriers. We're in Midland, Michigan. We have no idea how great we have it. And of course, there's still barriers, economic, but we have the ability to eat healthy here and I encourage you to do it. So let's decrease the height. In the US, diet peer supplements are not regulated to the same extent. They could throw whatever marketing thing they want and the FDA doesn't come down on them. They can say this is the most wonderful thing for you and no data at all to back it up. The law does not require them to pass clinical trials of safety and effectiveness before they can be offered to consumers. Manufacturers and sellers are not obliged to back up claims that their product works. It has been exceptionally difficult. The author of that paper said of 18 million live follow-up to convince people, including nutritional researchers, to acknowledge that vitamins and mineral supplements don't prevent heart disease. And we must encourage people to use proven methods to reduce the risk, eating healthier, exercising and avoiding tobacco. Why do we not eat healthy yet? We'll take the supplements. It doesn't, to me, seem to make sense. Now, I have nothing wrong with supplements. I told you I take them myself and I eat healthy. Yet I still take a multivitamin and I take some others and for maybe some other benefits. So if you really like the minerals and vitamins, I'm okay with that, but be sure you're doing the healthy things as well. Don't use them as a substitute for the other things. And finally, let's just go ahead to the last few slides. What are the best foods for heart health? Asparagus. You can get almost all these natural things in these colloene foods, asparagus, beans, peas, chickpeas, lentils, berries. It gets better. I know these are boring, but it gets better. Broccoli, flax seeds, fish high in omega-3. Our family, we love nice, we love the salmon. They're very rich omega-3 fatty acids. Green tea, nuts. Now it gets a lot better. Okay, oatmeal, still somewhat boring, but it's good. You'll lower your cholesterol with bran, spinach, tomatoes. Jennifer talked about the benefited tomatoes, vegetables. Okay, here we go. Coffee, ooh. You always hear about coffee. I have no idea what to tell patients because one year it's coffee's good, another it's no good, another it's good. Moderation. You know what? If you drink 16 cups of coffee a day and you're shaking your heart's out of rhythm, it's no good for you. If you drink one, two, or three, and it tolerates probably okay. Some studies say there are some benefits to it, others don't show it, so I don't know. Patients say I don't have a problem. If you don't have uncontrolled hypertension, if you don't have arrhythmias, tremors, the other things, then I'm okay with it, but be careful. Here it gets better. Dark chocolate. Dark chocolate is self-thought to be possibly. But again, I don't have randomized studies to show you this. These are some natural things that seem to be healthy. This one's even better. Red wine. So if you're a red wine drinker, I never tell people to start drinking alcohol because there's so many negatives. High blood pressure, obesity, triglycerides. But if you're drinking alcohol already and you're saying boy, you know, red wine does seem to have higher phenols and it could be more antioxidants. And then finally, a 24 ounce medium, bone and rib eye steak from the south side of Chicago serve with salted and buttered baked potato and corn on the cob. That's my Friday night. Just, but I'm kidding on this last one. So the point, the take home point is, you know, if you're gonna have a red meat, you're gonna go and have your steak. All right, do it. Do it in moderation. Get a, you know what? The portion size should be four ounces. If I go to a steak house and I pay $40 for a steak and I get four ounces, I'm gonna be a little upset about that, you know? But the size is four ounces and you're gonna want the leaner cuts of meat. So the filet doesn't have all that marble fat like I like in the rib eye. You're gonna trim off the fat. You're not gonna deep fry anything. You're gonna grill. So yes, do it. And you know, but the thing we're learning more and more is eating healthy, eating natural, eating Mediterranean and eating butter with that or some of the others is probably a lot healthier than going and grabbing the processed trans fat, trans fat, trans fat. All these chemicals, all this harmful stuff. So all those things I showed you are probably a safe bet other than this last one. So that is the end of my slides and I appreciate the good turnout and we do have a few minutes for some questions but not a lot of time. Yes. You forgot potato chips. Potato chips, you know. Potato chips. Yeah, be careful with the hypertension. Oh, somebody asked last week about arginine. Forget who asked me the question. And arginine is an amino acid, which we know and it's very important. It's a precursor to the most powerful vasodilator of all and blanking on the vasodilator. So let me just read. Oh, so arginine is an amino acid that's important in the synthesis of nitric oxide which is the most powerful vasodilator. It's what regulates your blood pressure, what regulates the coronaries. It's a very essential amino acid you can find in meats, in poultry. But again, we don't have data taking minerals that it does anything for you but it's one of those things again that I would certainly not be against to. And it is a very heart healthy precursor to this nitric oxide which we see diminished levels particularly in smokers who destroy the endothelium, the interlining and the blood vessel allowing them not to dilate properly. Those are the ones I put a wire in and the artery just spasms on me and I'm like, what is going on? The entire artery is clamping down on my catheter. They have lack of nitric oxide. So arginine is clearly beneficial. I just don't know and I can't find anything that says, you know, we've proven that you should take supplements. Yes. Put your thoughts on statins and peripheral neuropathy. There are statins. You mean do they cause it or do they help it or is there a? Put your thoughts on it. I've been told that's what's causing my illness. Oh, absolutely not. There's no correlation at all with nerve issues and statins. There's correlation with muscles. Numbness is a nerve problem. It's a neuropathy, exactly what you said. And I have no data to support that hypothesis. I would be careful to say it's the statin. I certainly, if I have debilitating neuropathy or chronic symptoms and I'm on statin, I'm on any med, I would certainly stop it if it's safe to stop and see if the symptoms get better but I've never seen this in the literature. It's quick. I'm reverse. Uh-huh. Does it get better? Well then you have to have a serious discussion with your doc. What are the risks versus the benefit? Yeah, I went through Ann Arbor. Yeah. Ann Arbor statin. Then I would not take it if there's any way. I haven't. Yeah. And then I would take, if you really need it, then I would take the PCSK9. That takes the. Right. So the only other lower class option is generic. The only one that has beneficial proven benefit is the now generic Zettia. Zettia will only lower the LDL on average about 16% versus the statins but for those that are truly statin intolerant, Zettia generic Zetamib is an alternative so that's something to think about. So when I say I don't know, I don't, that you know, in medicine you learn that it's not 100% science, there's some art. And if a patient's really telling you that they have this and you're that arrogant, not to listen and say impossible, I've never seen it before and you know, I haven't heard, you know, you're not doing your job as a physician then either. You can certainly educate and I can say, boy, you know, it's really not reported but interesting, you may have a cause and effect. Are you on a medicine that interacts with statins? Calcium block are very common in anti-rhythmic, a phenol fibrate, get rid of that first. But then like you, you know, that can be a serious life altering thing and remember I said quality of life. So I want to make your quality of life good. I just don't want to put you in a med that extends the life that the quality stinks. So if you've exhausted others, if they've looked at diabetes, ruled out other causes of neuropathy, can't find a treatable cause, you think it as a little better, I wouldn't take it. Yeah, anything else? Yeah. Mm-hmm. Is that healthy? Yeah, we think it does a bit. Certainly not harmful, you may get a little extra LDL reduction, it's gonna be minor, but again, very healthy, no problem with it. Is the antibiotic safe with Crestor or Antibiotics? Yes, but mainly with the mycins, erythromycin, chlorythromycin, the ones that work through that enzyme in the liver. And usually the antibiotics are short lips, so you're okay. But Crestor is pretty safe, it doesn't rely as heavily on that enzyme. Crestor is the one I take and Crestor you probably get away with more with interactions with others. And it's basically the mycine type antibiotics, or the age type of antiviral agents, but that's a whole nother ball game. For the standard antibiotics, you're generally okay for a short course, yeah. All right, oh, one more. One of your earlier slides talked about the risk, the different kinds of breast-to-heart smoking, of these things. I didn't see anything about genetics. Oh yeah, genetics, that was just her research study, so she was just using selected questions, but that's probably the biggest risk. And that's when you can't alter. So genetics is powerful. I mean, that's why you feel bad for somebody, they do everything right, and you know what, why am I in this situation? You had bad genetics. My father had high cholesterol, my mother had congestive heart failure towards end of her life, so all of my brothers and I we had heart problems in our fifties. Now genetics doesn't mean my father died of heart failure when he was 90, okay? As I told you, when you're 80, 80% of people have heart disease, so familial genetics is premature heart disease. Young age, men before 55, women before 45, women before 55, so strong predisposition. So you're right, good eye, boy, great, great attention today. She did not include it, but that's just because of her own survey, but family history of premature diseases is one of the most powerful. So if I have family history, and I say, you better make sure your kids, are your kids smoking? Do they have high blood pressure? Are they diabetic? To make sure that when they're 18, everything's checked out and they live a healthy lifestyle because that's the way you can delay it. But you're right, one of the most powerful risk factors of all. All right, great, this has been fun. And that is going to be the end of cholesterol. If Jenna, if you guys have other topics that are really interesting and if something I can help my wife with, I will be happy to come back, thank you.