Help with Cholesterol and BP Meds

[Ghoul]

An excellent point. To be clear, I'm not suggesting that everyone get on statins. I am suggesting that it's an effective intervention for ASCVD. Total cholesterol is not causal of arterial plaque burden, nor even closely correlated. LDL-C is not causal of arterial plaque burden, but is closely correlated. ApoB is directly causal of arterial plaque burden and happens to be traffic into the arterial walls by LDL. Even those ApoB is causal, it is considered necessary but not sufficient for the progression of ASCVD. It is possible to have high ApoB and yet still not suffer the progression of ASCVD. It is possible for people to have very high calcium scores and yet never have a MACE. One of the difficulties in this area is in interpreting the probabilities.



In as much as I can. I have an obvious bias. On the topic of statins, I've challenged that bias and attempted to find real data that supports the incidence of adverse side effects that people report. I've come up short.

I can deconstruct the studies you mentioned:

Total cholesterol and all-cause mortality by sex and age:

This is a large observational study that fails to show a linear relationship between total cholesterol and increased all cause mortality. I am not surprised, given what I wrote earlier. In many of these observational studies it's difficult to tease out a benefit in all cause mortality when deaths from ASCVD would represent a fraction of those. One could speculate about the reasons the u-shaped curve of all cause mortality vs. total cholesterol. In fact, we'd have to, because the paper doesn't really offer much.

Low Cholesterol is Associated With Mortality From Stroke, Heart Disease, and Cancer:

Again, this is another observational study in which people with low LDL that were *not* receiving any kind of lipid lowering medication had increased mortality. The lower LDL is correlated, but isn't causal. There could be any number of reasons why this may be the case.

Cholesterol and all-cause mortality in elderly people from the Honolulu Heart Program: a cohort study:

This is yet another observational study showing a correlation, but establishing no causal relationship.

In totality it suggests that across the entire population total cholesterol is not a good marker for deaths from all cause mortality, which I would readily accept. To some degree it refutes guidance from the medical community that "cholesterol is bad" and is an unfortunate failing on the part of the medical community to educate the general public.

None of that changes the fact that there are hosts of randomized clinical trials showing statins reducing the risk of death from ASCVD among patients at risk.

I know I am at risk. My aunt had an MI in her 40s. I had a CT-CAC a few years back and got a non-zero score, 48 I believe all of it in the LAD aka the "widow maker". My lipids weren't especially bad, but I'm running a multi-year experiment with N=1. My aim was to get ApoB below 60mg/dL as there's some literature that suggests that doing so may reverse calcified plaque. In full disclosure, it is promising, but not conclusive.

I began the process with all the non-pharmaceutical interventions. Diet, exercise, psyllium husk, fish oil, whatever. The needle moved a little. I tried ezetimibe mono-therapy. The needle moved a little. I was avoiding statins because they're a bugaboo. I had lunch with a friend of mine whom I hadn't seen in years. We were talking about such things. He was the prototypical American, obese, sedentary, poor health, shitty diet. Yet his lipids were significantly better than man on 20mg rosuvastatin. So, I decided to give it a whirl.

I started with a low dose, monitored for sides, experienced none, and continued. Eventually I added bempedoic acid and Repatha for the aforementioned reason in that I hope to reverse the calcified plaque, but also to create some headroom for my lipids to get worse as I increase my gear usage. Presently, they look like this:

View attachment 297208

As a result, I feel pretty good about the fact that I'm at 1.5g/wk and climbing.



You won't find simple to parse "life expectancy" data available for interventions for any other disease either. It's tremendously hard to do that math and even harder for the lay person to understand.

In the case of friend who has a family history of CVD, high triglycerides, high LDL but is cardiovascularly asymptomatic, what diagnostics and treatments would you advise them would be the highest priority?

IE.

I'd have this checked, then this. Address LDL or triglycerides first, that sort of thing .

I guess I'm describing a patient who wants to be proactive, and not passively assume a doctors plan is ideal, when "resource conservation" and other concerns may take precedence over what's actually ideal.

And yes, BP under control, of course, lol.

 

[egruberman]

In the case of friend who has a family history of CVD, high triglycerides, high LDL but is cardiovascularly asymptomatic, what diagnostics and treatments would you advise them would be the highest priority?

IE.

I'd have this checked, then this. Address LDL or triglycerides first, that sort of thing .

I guess aim describing a patient who wants to be proactive, and not passively assume a doctors plan is ideal, when "resource conservation" and other concerns may take
precedence over what's actually ideal.

Kinda depends on age and lifestyle. High trigs is one of those things that is generally associated with the progression of ASCVD. Let's do this:

Get lifestyle sorted. Reduce saturated fat, get 180 minutes of zone 2 cardio a week, eat a diet rich in fiber and vegetables. Make sure BP is managed <120/80. Identify and eliminate sources of inflammation.

Get an NMR lipid panel to have a look at ApoB and Lp(a). Lp(a) is a genetically predetermined biomarker that can't be managed other than with PCSK9i. Think of it as a risk multiplier. What ever risk exists is 2 or 3 fold with a high Lp(a). I use the CardioIQ Advanced Lipid Panel from quest which I get through walkin labs. Lab 92145.

ApoB is then the thing that needs to be managed. If the person is young-ish I'd aim for an ApoB of 80mg/dL. If the person has a high risk, say a family history and very high ApoB, I'd maybe aim for 60mg/dL. I'm parroting these numbers from Tom Dayspring BTW.

To further cement the decision to manage ApoB, get a CT-CAC. It's generally less than $200 self pay. Find one with a low radiation dose, i.e. 2mSv or lower which is most common, so that shouldn't be hard. A non-zero result suggests the presence of calcified plaque which means that ASCVD has progressed quite a bit. A score <100 is "mild" and I'd still aim to get ApoB to 60mg/dL or lower. A score >100 would, in my mind, merit everything the person could tolerate.

 

[Ghoul]

Kinda depends on age and lifestyle. High trigs is one of those things that is generally associated with the progression of ASCVD. Let's do this:

Get lifestyle sorted. Reduce saturated fat, get 180 minutes of zone 2 cardio a week, eat a diet rich in fiber and vegetables. Make sure BP is managed <120/80. Identify and eliminate sources of inflammation.

Get an NMR lipid panel to have a look at ApoB and Lp(a). Lp(a) is a genetically predetermined biomarker that can't be managed other than with PCSK9i. Think of it as a risk multiplier. What ever risk exists is 2 or 3 fold with a high Lp(a). I use the CardioIQ Advanced Lipid Panel from quest which I get through walkin labs. Lab 92145.

ApoB is then the thing that needs to be managed. If the person is young-ish I'd aim for an ApoB of 80mg/dL. If the person has a high risk, say a family history and very high ApoB, I'd maybe aim for 60mg/dL. I'm parroting these numbers from Tom Dayspring BTW.

To further cement the decision to manage ApoB, get a CT-CAC. It's generally less than $200 self pay. Find one with a low radiation dose, i.e. 2mSv or lower which is most common, so that shouldn't be hard. A non-zero result suggests the presence of calcified plaque which means that ASCVD has progressed quite a bit. A score <100 is "mild" and I'd still aim to get ApoB to 60mg/dL or lower. A score >100 would, in my mind, merit everything the person could tolerate.

Brilliant. Just what's needed to get the ball rolling. Thanks. Will return with my. er, friend's results.

 

[buck]

An excellent point. To be clear, I'm not suggesting that everyone get on statins. I am suggesting that it's an effective intervention for ASCVD. Total cholesterol is not causal of arterial plaque burden, nor even closely correlated. LDL-C is not causal of arterial plaque burden, but is closely correlated. ApoB is directly causal of arterial plaque burden and happens to be traffic into the arterial walls by LDL. Even those ApoB is causal, it is considered necessary but not sufficient for the progression of ASCVD. It is possible to have high ApoB and yet still not suffer the progression of ASCVD. It is possible for people to have very high calcium scores and yet never have a MACE. One of the difficulties in this area is in interpreting the probabilities.



In as much as I can. I have an obvious bias. On the topic of statins, I've challenged that bias and attempted to find real data that supports the incidence of adverse side effects that people report. I've come up short.

I can deconstruct the studies you mentioned:

Total cholesterol and all-cause mortality by sex and age:

This is a large observational study that fails to show a linear relationship between total cholesterol and increased all cause mortality. I am not surprised, given what I wrote earlier. In many of these observational studies it's difficult to tease out a benefit in all cause mortality when deaths from ASCVD would represent a fraction of those. One could speculate about the reasons the u-shaped curve of all cause mortality vs. total cholesterol. In fact, we'd have to, because the paper doesn't really offer much.

Low Cholesterol is Associated With Mortality From Stroke, Heart Disease, and Cancer:

Again, this is another observational study in which people with low LDL that were *not* receiving any kind of lipid lowering medication had increased mortality. The lower LDL is correlated, but isn't causal. There could be any number of reasons why this may be the case.

Cholesterol and all-cause mortality in elderly people from the Honolulu Heart Program: a cohort study:

This is yet another observational study showing a correlation, but establishing no causal relationship.

In totality it suggests that across the entire population total cholesterol is not a good marker for deaths from all cause mortality, which I would readily accept. To some degree it refutes guidance from the medical community that "cholesterol is bad" and is an unfortunate failing on the part of the medical community to educate the general public.

None of that changes the fact that there are hosts of randomized clinical trials showing statins reducing the risk of death from ASCVD among patients at risk.

I know I am at risk. My aunt had an MI in her 40s. I had a CT-CAC a few years back and got a non-zero score, 48 I believe all of it in the LAD aka the "widow maker". My lipids weren't especially bad, but I'm running a multi-year experiment with N=1. My aim was to get ApoB below 60mg/dL as there's some literature that suggests that doing so may reverse calcified plaque. In full disclosure, it is promising, but not conclusive.

I began the process with all the non-pharmaceutical interventions. Diet, exercise, psyllium husk, fish oil, whatever. The needle moved a little. I tried ezetimibe mono-therapy. The needle moved a little. I was avoiding statins because they're a bugaboo. I had lunch with a friend of mine whom I hadn't seen in years. We were talking about such things. He was the prototypical American, obese, sedentary, poor health, shitty diet. Yet his lipids were significantly better than man on 20mg rosuvastatin. So, I decided to give it a whirl.

I started with a low dose, monitored for sides, experienced none, and continued. Eventually I added bempedoic acid and Repatha for the aforementioned reason in that I hope to reverse the calcified plaque, but also to create some headroom for my lipids to get worse as I increase my gear usage. Presently, they look like this:

View attachment 297208

As a result, I feel pretty good about the fact that I'm at 1.5g/wk and climbing.



You won't find simple to parse "life expectancy" data available for interventions for any other disease either. It's tremendously hard to do that math and even harder for the lay person to understand.

And i have still seen no studies that show as a group stains increase the life expectancy of those that use them on the average. For a select high risk group possibly. And i realize that medicine only looks at it's own little field of study. But in the end the only thing i am interested in is what will better my life .I look at health. Hence the reason i came to the conclusion that BP, glucose are at healthier levels below what medicine recognizes. I look at where life expectancy drops off and find that a better gauge then the recommendations from the government which sets the guidelines for medicine. Big pharma has the decades of data that they point out how many less cardiac incidents there are. And they would also have the data to show how many died as well.

And while i agree with many things you have said. I can tell you from my experience that it seems that Dr. on the whole don't. Last year 2 different cardiologists from different organizations that are well respected both saw i had calcification of the arteries and automatically recommended a statin. Neither looked at my blood work of they would have noticed my LDL was 75 for years, naturally. And neither cared about APOB etc. Only LDL. When quizzed one got defensive and the other finally admitted a statin would likely do me no good and may have negative effects. But he still recommended it as that is what Dr are trained to do. We both had a good laugh.

 

[Ghoul]

A very timely article confirming what's been known for years. Multiple low dose BP meds, in a single pill, are better than one higher dose med.

This research proves Telmisartan, Amlodipine (sound familiar lol), and a diuretic given in micro doses should be the first treatment even in moderate blood pressure.

Most telling however, is the reference to how difficult it is to get doctors to even prescribe a DUAL combo, despite its proven superiority, because "they were taught to max the dose of a single medication first". Essentially, to make their jobs easier if there are any sides. Despite a decade proving this is the wrong approach.

Finally, they also mention most BP treatment is a single drug pill prescribed upon initial diagnosis, BP falls slightly, and that's it. No follow up, ever. No attempt to reach ideal BP target, despite the mountain of evidence of how much that improves long term outcomes involving every single organ. It's infuriating!

Anyway, we got OP off to the right start here with a dual class BP med, and we'll get him to 120/70 over time.

Proof the MESO community can literally save your life, though all too often that means saving it from medical apathy.

New Hypertension Approach Hits Multiple Targets at Low Dose

Single-pill combinations of three or more antihypertensive drugs are the way forward to help patients reach lower blood pressure targets, according to experts evaluating the approach.

www.medscape.com

 

[egruberman]

And i have still seen no studies that show as a group stains increase the life expectancy of those that use them on the average. For a select high risk group possibly.

There are no studies that will show you an increase in life expectancy. There are studies that will show fewer incidences of death.

And while i agree with many things you have said. I can tell you from my experience that it seems that Dr. on the whole don't.

I think I started this diatribe by stating how the ACC (American College of Cardiology) is still stuck in the past. The standard of care is high dose statin mono-therapy, which I think they renewed in 2022 or 2023 to my utter chagrin.

the other finally admitted a statin would likely do me no good and may have negative effects.

Yeah, I can't believe this. I don't know the complete details, but a statin may extend your life.

both saw i had calcification of the arteries

They both did a CT-CAC? What was your calcium score?

Neither looked at my blood work of they would have noticed my LDL was 75 for years, naturally. And neither cared about APOB etc. Only LDL.

Yeah, that's unfortunate. You may have elevated Lp(a) or there may be other issues if you have calcified plaque burden.

Just so we're clear, the progression of ASCVD is linear with regard to exposure to ApoB. You've already been made aware of the fact that you have ASCVD as evidenced by the calcified plaque. A statin or any other lipid lowering drug will reduce your exposure to ApoB and by consequence the accumulation of plaque burden.

Nobody can tell you at what point that increased plaque burden causes an MI. Medical technology being what it is. Once you have a heart attack, if you live, very likely you will live quite some time beyond that. I think it's been 20 years since my aunt had an MI and she's doing reasonably well.

I wish I could convince you to take this seriously, but it seems that you are going to believe what you want to believe. Good luck.

 

[buck]

There are no studies that will show you an increase in life expectancy. There are studies that will show fewer incidences of death.



I think I started this diatribe by stating how the ACC (American College of Cardiology) is still stuck in the past. The standard of care is high dose statin mono-therapy, which I think they renewed in 2022 or 2023 to my utter chagrin.



Yeah, I can't believe this. I don't know the complete details, but a statin may extend your life.


They both did a CT-CAC? What was your calcium score?



Yeah, that's unfortunate. You may have elevated Lp(a) or there may be other issues if you have calcified plaque burden.

Just so we're clear, the progression of ASCVD is linear with regard to exposure to ApoB. You've already been made aware of the fact that you have ASCVD as evidenced by the calcified plaque. A statin or any other lipid lowering drug will reduce your exposure to ApoB and by consequence the accumulation of plaque burden.

Nobody can tell you at what point that increased plaque burden causes an MI. Medical technology being what it is. Once you have a heart attack, if you live, very likely you will live quite some time beyond that. I think it's been 20 years since my aunt had an MI and she's doing reasonably well.

I wish I could convince you to take this seriously, but it seems that you are going to believe what you want to believe. Good luck.

Most all data i have seen show life expectancy going up about 3-90 days at most. None show years. And that is if statin are taken long term. I have to wonder if it is worth it with what the quality is like for those extra days considering the side effects. It seems the stains may help stave off the first or smaller heart attack but in the end things turn out much the same.

My calcium score is around 550.

My ApoB is low from the tests i have had done in my own recently As my total cholesterol has been around 150 and LDL round 80. I tend to think my ApoB has likely always been low as well. I find much of what causes cardiac issues is really not just cholesterol related and is likely smaller then what is put forth. But that is what medicine focuses on. Ever since the US senate decided that was the problem back in the 1940's

MY cholesterol LDL VLDL. BP, glucose, inflammatory markers etc have all been to the low side for decades. Ate healthy exercised did aerobics etc.

From my reading i tend to think the calcification is from decades of intense training. And the high BP that ensues along with the inflammation. As a few studies i have seen show Intense training long term whether lifting or aerobics tend to leave people with higher calcification then the normal population.

All the imagining i have done shows not blockages. Only calcium to the outside of the arteries. Lowering my LDL from 75 down to 70 was why the Dr said he thought there be be no benefit to me as that is not much.

I can only go be what Dr's and what standard medicine prescribes. I have never gotten Dr.s to do as i see fit. Then i am on my own, which i don't mind. I decided long ago between heart attack, stroke and cancer the heart attack sounds best to me. I worry more about cancer.

Evaluation of Time to Benefit of Statins for the Primary Prevention of Cardiovascular Events in Adults Aged 50 to 75 Years: A Meta-analysis

This meta-analysis assesses randomized clinical trials of statins to determine the time to benefit for prevention of a first major adverse cardiovascular event in adults aged 50 to 75 years.What is the time to benefit of statin therapy for primary prevention ...

www.ncbi.nlm.nih.gov

Personalized Prediction of Lifetime Benefits with Statin Therapy for Asymptomatic Individuals: A Modeling Study

In a modeling study conducted by Myriam Hunink and colleagues, a population-based cohort from Rotterdam is used to predict the possible lifetime benefits of statin therapy, on a personalized basis.Physicians need to inform asymptomatic individuals about ...

www.ncbi.nlm.nih.gov

The effect of statins on average survival in randomised trials, an analysis of end point postponement - PubMed

Statin treatment results in a surprisingly small average gain in overall survival within the trials' running time. For patients whose life expectancy is limited or who have adverse effects of treatment, withholding statin therapy should be considered.

pubmed.ncbi.nlm.nih.gov

 

[egruberman]

I have to wonder if it is worth it with what the quality is like for those extra days considering the side effects. It seems the stains may help stave off the first or smaller heart attack but in the end things turn out much the same.

Is it worth it considering the side effects? I have none, most have none, so yeah, I'd say so. In the event that someone experiences side effects, there are other compounds listed above.

As for your specific case, you'd be an outlier. Have you checked Lp(a)?

 

[buck]

Is it worth it considering the side effects? I have none, most have none, so yeah, I'd say so. In the event that someone experiences side effects, there are other compounds listed above.

As for your specific case, you'd be an outlier. Have you checked Lp(a)?

Well when there is likely no upside to taking it them as per 1 specialist i have spoken to, yes side effects are defiantly to be considered. But when i look at the rate increase for cancer stroke etc. Those are also a possible side effect to consider. And i am more concerned with them then a heart attack. We all have our own ideas of what is important to us. I look long term And as i showed there is not a great deal of evidence showing any increase in life expectancy. And from the many people i know on statins i don't see where quality has improved. Only a little peace of mind that they are on them. But i don't get that same warm fuzzy feeling from the idea of taking them. People should do what is in their comfort zone.