Tuesday, 29 June 2010

Waist Circumferance

A free tape measure from British Heart Foundation 'Heart Matters' waist measurement.

Crabsallover waist 99cm (at 12st 2 pounds) - increasing health risks according to the tape or according to table below "your health is at risk".

Sharon 37" - health at risk.

Click image below "how to measure your waist" and for measurements "your health is at risk" or "your health is at high risk".

Join Heart Matters from BHF - receive a free tape measure .... and a lot more.

Sunday, 27 June 2010

Risk Factors for strokes

reposted from: NHS Choices.

The conclusion that "targeted interventions that reduce blood pressure and smoking, and promote physical activity and a healthy diet, could substantially reduce the global burden of stroke", seems sensible says NHS Choices.

Saturday, 26 June 2010

The European cardiovascular disease risk assessment model

Systematic COronary Risk Evaluation (SCORE): High & Low cardiovascular Risk Charts based on gender, age, total cholesterol, systolic blood pressure and smoking status, with relative risk chart, qualifiers and instructions

SCORE risk charts for high risk countries (incl. UK): pdf

Wednesday, 23 June 2010

NICE review of cost effectiveness of Statins

2006 review by NICE includes trial data, benefits and cost effectiveness of statins in preventing CVD

NICE recommendations on how to reduce CVD (Cardiovascular disease)

reposted from: NHS Choices

Protect the population from the harmful effects of trans fats
  • Eliminate the use of industrially produced trans fatty acids (IPTFAs) for human consumption.
  • In line with other EU countries (specifically Denmark and Austria), introduce legislation to ensure that IPTFA levels do not exceed 2% in the fats and oils used in food manufacturing and cooking.
  • Establish guidelines for local authorities to independently monitor IPTFA levels in the restaurant, fast-food and home food trades using existing statutory powers (in relation to trading standards or environmental health)

Does this guidance apply to me?

This guidance is aimed at improving the health of the population as a whole. It makes recommendations to people who can make changes to improve population health.
However, the principles underlying the recommendations also apply to individuals. For example, most people should reduce their salt, saturated fat and trans fat intake, as well as increasing their levels of physical activity.
Related NICE guidance focuses more on individuals, including guidance on stopping and preventing smoking and tobacco control, physical activity, obesity, high blood pressure and mother and child nutrition.

Links To The Headlines

Slash salt to 'prevent thousands of deaths. Daily Express, June 22 2010
Plea to stop using trans-fats. Financial Times, June 22 2010
5-point plan to save 40,000 lives. Daily Mirror, June 22 2010

Links To Science

Monday, 21 June 2010

Total, LDL, HDL cholesterol

Blood Levels mmol/L (millimole per litre) reposted from: wiki via HDL wiki

Optimal Cholesterol Values Range (mmol/L)
Total (2.4 to 3.9) = HDL (1 to 2) + LDL (1.5 to 2.5)

Optimal Cholesterol Values (mmol/L)
Total (3.5) = HDL (1.5) + LDL (2.0)

Usual Cholesterol Values (mmol/L)

Total (3 to 6.5) = HDL (0.9 to 2) + LDL (2 to 3.5)

If total cholesterol is 5 mmol/L to 3.5 mmol/L is a 30% reduction.

Glucose (fasting) values (diabetes test)
3.8 to 6 mmol/L

Triglycerides (40-59 years) Range
0.7 to 1.7 mmol/L.
People with high triglyceride levels have a greater risk of developing cardiovascular disease than people with lower levels. (source)

C-Reactive Protein (nmol/L)

CRP Range: 65 to 250 nmol/L.

Elevated C-reactive protein levels (wiki) have been shown to be an early indicator of heart attack even when cholesterol levels are 'normal'. C-reactive protein (CRP) is a protein found in the blood, the levels of which rise in response to inflammation. Its role is to bind to phosphocholine expressed on the surface of dying cells (and some bacteria) beginning the phagocytotic immunologic response.

Kurzweil & Grossman in Transcend (2009) 

Friday, 18 June 2010

Millions could be put on statins

Millions more healthy people could be put on cholesterol-lowering drugs.
Tuesday, 10 February 2009 Source: BBC
England's heart tsar Roger Boyle said the government's rationing body should look at the issue after a study showed statins nearly halve heart attack risk.
The research in Archives of Internal Medicine shows the drugs are even more effective than previously thought.
Under current plans around one in four adults aged over 40 is to be prescribed statins on the NHS. GPs will begin the risk assessments later this year.
As well as heart risk, they will check all patients aged 40 to 74 for stroke risk and kidney disease.
 It is highly likely that the threshold for using statins in primary prevention will fall 
Peter Weissberg of the British Heart Foundation
It is projected that 15 million people will benefit from the checks, which will be phased in over five years. A Department of Health spokesman said they expected the number of statin prescriptions to increase by 30% per year.
Similar checks already occur in Scotland for people living in the most deprived areas.
Current guidelines from the National Institute for Health and Clinical Excellence for England and Wales, and SIGN in Scotland, recommend that anyone judged to have a one in five or greater risk of developing cardiovascular disease over 10 years should be taking a statin drug.
But the latest study of nearly 230,000 people, by investigators at Maccabi Healthcare Services and Sackler Faculty of Medicine in Tel Aviv, Israel, shows the drugs also benefit those at even lower risk - one in 10 - of developing cardiovascular disease.
This, say the researchers, means even more people over 40 should be taking statin drugs, even if they have no obvious signs of illness - which is called primary prevention.
The drugs are already given to patients with cardiovascular disease (CVD) - secondary prevention. In England and Wales alone about four million people are on them.
Widening the net could mean between six and seven million people taking them.
Cost effective
Some experts believe we are already prescribing too many statins, and there is a danger of turning healthy people into patients and making them worry about their health unnecessarily.
But Professor Boyle, the national director for heart disease and stroke, said the move would save thousands of lives each year.
Statins are a relatively cheap medication - a month's supply for a patient can cost as little as £1.39 if doctors prescribe a generic rather than a brand-name drug.
But the price tag for the nation would be billions.
Professor Boyle told The Telegraph cost was "not an issue".
A Department of Health spokesman said the current guidelines recommend that "when therapy is initiated, the statin chosen should usually be of low acquisition cost".
Peter Weissberg of the British Heart Foundation said: "In the UK prescription of statins for primary prevention is currently confined to those considered to be at high risk of developing heart disease. As the evidence accumulates and statins become less expensive it is highly likely that the threshold for using statins in primary prevention will fall."
A NICE spokesperson said: "NICE is committed to ensuring that its guidance is up-to-date through a planned programme of reviews which consider all the relevant evidence published since the original guidance.
"In order to be completely confident that a review of the statins guidance is appropriate, we have asked consultees and commentators to inform us of any evidence that suggests a review would be beneficial.
"The deadline for comments on the review proposal paper closed yesterday and we hope to confirm at the end of March 2009 if the current NICE guidance on statins will be reviewed.
"Current NICE guidance recommends that statins are used either where there is clinical evidence of an individual having CVD, or where the risk of an individual developing CVD within 10 years is estimated to be 20% or greater."

Thursday, 17 June 2010

Wider use of statin drugs

Tuesday February 10 2009
Statins reduce cholesterol levels, which can effect heart health

“Millions of healthy people with no obvious sign of illness could be put on cholesterol-lowering drugs” says The Daily Telegraph. The front-page story discusses the possibility that these cholesterol-reducing statin drugs might be more widely prescribed as a measure to cut the risk of health problems like heart attacks. The newspaper also highlights new research that it says shows statins are even more effective than was previously thought for people who appear healthy.
For several years the study followed the use of statins by 230,000 people with and without cardiovascular disease. It was designed to test what happens in practice when people discontinue statins, rather than to compare people who took statins to those who did not. It found that those who took over 90% of their medication reduced their risk of death by 45% compared with people who only took 10% of their medication.
Raised cholesterol has long been recognised as one of the risk factors for heart attacks, and statins are a valuable daily protective medication for people at risk of a cardiovascular event such as a heart attack. However, statins can have harmful effects and are not required for everyone.
Each person who is considered for statin medication should continue to have their individual coronary (heart-related) risk assessed according to their blood cholesterol level, age, sex and the presence of other risk factors such as diabetes, high blood pressure and smoking.

Where did the story come from? 

This research was conducted by Dr Varda Shalev and colleagues of the Medical Division, Maccabi Healthcare Services (MHS), and Sackler Faculty of Medicine, Tel Aviv University, Israel. No sources of funding were reported. The study was published inArchives of Internal Medicine, a peer-reviewed medical journal.

What kind of scientific study was this? 

This was a cohort study investigating the effect that statin drugs have on death from any cause in people with and without a history of cardiovascular disease. The researchers also looked at mortality in people who already have established cardiovascular disease, although evidence in this area is already more clearly established.
The researchers examined medical records from MHS, the principal health organisation in Israel. They identified all new users of statins between January 1998 and December 2006, with statin use being defined as having at least one prescription filled within this period. The date of first prescription was used to define an index date for subjects. This gave a total of 229,918 eligible people.
The researchers divided the cohort into two: those with any diagnosis of cardiovascular disease prior to the prescription (hence taking statins as secondary prevention against another cardiac event), and those without any identifiable cardiovascular disease diagnosis prior to prescription (taking a statin for primary prevention). All information on medical diagnoses was identified through the MHS and medical records, laboratory reports, hospital notes and so on.
From the index date, the researchers looked at the period of time statins were first taken until either time of death, leaving the MHS or the end of the study period (December 2006), whichever came first. Statin medications were classed into three groups (low, moderate and high efficacy) according to the drug used and dose taken.
They also collected information on socioeconomic data, disability, other hospital admissions and outpatient visits, and other prescription drugs. Information on mortality was obtained through the Israel National Population Registry and the National Insurance Institute.

What were the results of the study?  

A total of 93,866 individuals in the secondary prevention group (those with established cardiovascular disease) and 136,052 individuals in the primary prevention group (those without) were identified as being newly treated with statin drugs during the study period.
The total study population was reported to be representative and was 21.6% of the entire MHS adult population. There were equal proportions of men and women in the cohort and average age was 57.6 years, with slightly older people in the secondary prevention group. 
During the study period, 13,165 individuals (5.7%) died and 3,745 (1.6%) left the MHS. Within the primary prevention group (those with cardiovascular disease) the average follow-up was 4.0 years. The group featured 4,259 deaths (7.8 per 1,000 person years). Within the secondary prevention group the average follow-up time was 5.0 years, and there were 8,906 deaths (19.0 per 1,000 person years). Several medical comorbidities were associated with increased risk of death, for example diabetes, cancer and high blood pressure.
Continuity of statin use was defined in terms of “proportion of days covered” (PDC). In both groups, a PDC of 90% was associated with at least a 45% reduction in risk of death from any cause compared with those with a PDC of less than 10%. Also, in both groups, reduction in mortality risk was greatest by a significant degree for those who were treated initially with a high-efficacy statin. 

What interpretations did the researchers draw from these results?  

The researchers conclude that improved continuity of statin treatment provides an ongoing reduction in deaths from any cause among people with and without a known history of cardiovascular disease.
They also say the observed benefits from statins were greater than shown by previous randomised controlled trials.

What does the NHS Knowledge Service make of this study?  

This study has demonstrated a link between improved overall survival and use of statins in people with and without known cardiovascular disease. The study is strengthened by being of very large size, having a relatively long duration of follow-up and including a large proportion of adults enrolled in the Israel health system who were taking statins.
There are points to note when interpreting this research:
  • The study featured several statistical comparisons to look for different associations between statin use, other factors and risk of death from any cause. This may have increased the risk of inaccuracy in the risk estimates.
  • Although the study has used reliable sources of data, there is still the possibility of missed or inaccurate information on the duration or frequency of statin use or misclassification of medical diagnoses. Continuity of statin use was estimated based on dispensing information, but whether or not statins were dispensed cannot prove that they were actually taken.
  • One limitation to the conclusions of this study is that, though there is mention of the reduction in risk of mortality being greater than previously demonstrated in clinical trials, all people in this study were using statins, and so investigation of whether statin use reduced risk compared to no use of statins was not tested. Randomisation to statin use or not would still be the best way to assess whether statin use reduced overall risk of death.
  • All people in this study were using statins, and so investigation of whether statin use reduced risk compared to no use of statins was not tested. Despite adjustments made in the study design it is possible that people who stop taking statins are different in some way, for example having poorer health behaviour in general, than those who continue taking the drugs. This might have affected the increased risk of death.
Statins can have adverse effects and are not needed by everyone. Each person who is being considered for a statin medication should continue to have their individual coronary risk assessed according to their blood cholesterol level, age, sex and presence of other risk factors such as diabetes, high blood pressure and smoking.

Links to the headlines

Millions of statins will go to low-risk over 40s. The Daily Telegraph,February 09 2009
Millions could be put on statins. BBC online, February 09 2009

Links to the science

Shalev V, Chodick G, Silber H et al. Continuation of Statin Treatment and All-Cause Mortality: A Population-Based Cohort Study. Arch Intern Med.2009;169(3):216.

Statin side effects examined

The benefits of statins outweigh
the risk of side effects
Friday May 21 2010

“GPs should think more carefully about prescribing cholesterol-busting drugs,” reported BBC News, adding that some statin drugs raised the risk of adverse effects such as liver and kidney problems.

The research used medical records on over 2 million patients to assess side effects of cholesterol-lowering statin drugs. Clinical trials to approve a drug tend to look at side effects in a selected population over a relatively short time. This study monitored patients in general practice over a longer period of time, which allows rarer side effects to be revealed. The study confirmed some side effects that are already known, such as an increased risk of muscle weakness, cataracts, acute kidney failure, and moderate or severe liver dysfunction.

However, these problems were still estimated to be quite rare, with cataracts affecting less than 3% of statin users and other side effects less than 1%. A greater number of patients benefited from taking statins to lower cholesterol, which in turn prevented heart attacks. This study provides invaluable numerical data for clinicians that will help them weigh up the risks and benefits of these drugs for each patient.

Where did the story come from?

The study was carried out by researchers from Nottingham University, who received no external funding. The study was published in the peer-reviewed British Medical Journal. The research was covered appropriately by national newspapers, which all included a pertinent quote from the British Heart Foundation: "A small number experience side-effects but the benefits far outweigh the risks." However, some stories do not make it explicit that the overall risk of side effects remains quite small among statin users.

What kind of research was this?

Statins are cholesterol-lowering drugs that are prescribed to reduce the risk of heart disease among high-risk patients. The researchers say that statins are among the most widely prescribed medicines and that their use is likely to increase. This was a prospective cohort study that investigated side effects of statins. Clinical trials of drugs tend to assess side effects of drugs over the short term, typically about five years. This type of study is appropriate for looking at potential long-term side effects in a large, unselected population.

What did the research involve?

The researchers used data from the general practice research database for England and Wales, which contains anonymous patient information on prescriptions and medical history contributed by GPs. The researchers selected a cohort of patients (both users and non-users of statins) aged 30 to 84 years that were registered at GP practices between January 2002 and June 2008. Patients entered the cohort either 12 months after they had first registered with the GP or when they were prescribed statins for the first time. Statin use was classified by the type of statin first prescribed and the starting dose. In total, approximately 2 million patients’ medical records were analysed from across 368 GP practices. The researchers looked for moderate or serious myopathy (muscle weakness or pain) and defined this in the study as a diagnosis of myopathy or rhabdomyolysis (a type of muscle breakdown). In the event of diagnosis of myopathy or rhabdomyolysis, treatment is likely to be discontinued. Diagnoses were made by the GP or through a blood test showing four abnormal levels of an enzyme called creatine kinase.

What were the basic results?

At study entry, 1,778,770 (83.8%) had not been prescribed statins, 9,513 (0.5%) were past users, 107,581(5.1%) were current users and 225,922(10.7%) were first users. Simvastatin was the most commonly prescribed statin, with 70.7% of new users being prescribed this drug). Compared to non-users, new users were more likely to be men, to be older and to have conditions such as atrial fibrillation, heart disease, vascular disease, high blood pressure, diabetes and kidney disease. The researchers found that the outcomes that were significantly associated with statin use were myopathy (muscle weakness or pain), cataracts, kidney failure, and moderate or severe liver dysfunction. Out of the cohort, 15,020 had moderate or serious liver dysfunction. Statin use increased the risk of liver dysfunction approximately two fold in both men and women, with the highest risk associated with fluvastatin. Female hazard ratio (HR) of 2.53 (95% CI 1.84 to 3.47), male hazard ratio (HR) of 1.97 (95% CI 1.43 to 2.72). The risk of liver dysfunction was associated with the size of fluvastatin dose. The risk across all statins was highest in the first year of statin use.

After stopping statins the risk decreased to that of a non-user within one to three years in women and after three years in men. Out of the total cohort, 1,406 developed moderate or severe myopathy. Statins increased the risk of myopathy approximately three to seven fold, 
although the risk did not vary by type of statin.

The risk was highest in the first year of taking statins, although the risk persisted after stopping treatment. Out of the whole cohort of statin users and non-users 36,541 individuals developed cataracts, with the
risk of cataracts being between 1.25 and 1.56 times greater among statin users than among non-users. 
There were no differences in risk for the different types of statin. The risk returned to normal within the first year of stopping treatment.

There were 1,969 cases of kidney dysfunction. The risks associated with statins ranged from 50% increased risk to a 100% increased risk (i.e. double). The risk remained during the first year of stopping treatment, but returned to normal one to three years after stopping treatment.

Alongside these side effects the researchers found that statins actually lowered the risk of oesophageal (throat) cancer in both men prescribed simvastatin (HR 0.69, 95% CI 0.50 to 0.94) and women prescribed simvastatin (HR 0.82, 95% CI 0.68 to 0.99). Across the total cohort 1,809 people developed oesophageal cancer.

The researchers estimated that for every 10,000 women treated with statins there would be 271 fewer who developed cardiovascular disease and 301 fewer men for every 10,000 treated. However, for these 10,000 people there would be 17 extra cases of kidney problems, 252 cases of cataracts, 65 people with liver problems and 32 extra cases of myopathy.

How did the researchers interpret the results?

The researchers report that they were able to quantify adverse effects associated with statins, including myopathy, liver dysfunction, acute renal failure and cataracts. These seem to be ‘class effects’, meaning they are generally consistent across all types of statin rather than varying according to individual drugs. There was a ‘dose-response effect’ (larger doses had larger effects) for acute renal failure and liver dysfunction consistent with that reported elsewhere. The researchers say that adverse effects tended to be similar across the types of statins for most outcomes except for liver dysfunction, where the highest risks were associated with fluvastatin.


This is a large and well-conducted study that has shown that there was an increased risk of myopathy (muscle weakness), cataracts, kidney failure, and moderate or severe liver dysfunction associated with statin use. However, very few in the study population (non-users and users of statins) developed the conditions, suggesting that it is important for people considering these drugs to have an understanding of their individual chances of any side effect when compared to the potential benefit. The study did show that fluvastatin gave the highest risks for liver dysfunction and this may affect the choice of which statin to prescribe. This research has looked at the risks and benefits of statins and has provided useful estimates of the absolute risks (the estimated number of extra cases of side effects for every 10,000 patients treated). It should be remembered that the benefits of statins seem to outweigh the risk of side effects for most people. These estimates constitute invaluable numerical data for clinicians, helping them consider the likelihood of specific risks and benefits on a patient-by-patient basis. Members of the public should not alter their use of medication without appropriate medical guidance from a doctor or pharmacist, who can discuss any concerns they may have about statins.

Links to the headlines

Statins 'raise chances of kidney failure and cataracts'. The Daily Telegraph, May 21 2010 Liver failure warning on statin drugs. Daily Mirror, May 21 2010 Statin side-effect risk uncovered. BBC News, May 21 2010 Statins: The side effects 'are worse than feared'. Daily Mail, May 21 2010 Statins can be risk to health. Daily Express, May 21 2010

Links to the science

Hippisley-Cox J, and C Coupland. Unintended effects of statins in men and women in England and Wales: population based cohort study using the QResearch database. BMJ 2010;340:c219

Rapid Responses
selection of letters

Monday, 14 June 2010

NHS Choice guidance on taking Statins


When to avoid statins

Statins should not be taken if you have:
  • liver disease
  • persistently abnormal liver function blood tests
Before you start taking a statin, your doctor should ensure your liver function is normal. This involves carrying out a blood test to check for the liver enzyme (substance in the blood) serum transaminase.
This should be repeated one to three months after you start taking the statin and at six-month to one-year intervals while you are taking it. If the amount of serum transaminase in your blood rises to and stays at three times the upper limit of normal, your doctor will advise you to stop taking the statin.

Using statins with caution

Statins should be taken with caution if you have risk factors for developing the rare side effects of myopathy and rhabdomyolysis (types of muscle disorder that cause muscle pain and breakdown of muscle tissue). These risk factors include:
  • being over 70 years old
  • having a history of liver disease
  • drinking large quantities of alcohol
  • having a history of muscle side effects when taking a statin or fibrate (another type of medicine for high cholesterol)
  • having a family history of myopathy (muscle damage) or rhabdomyolysis (kidney damage caused by a substance called myoglobin that is released into the blood when your muscles are inflamed or damaged)
If you have an underactive thyroid, only take a statin if your thyroid problem is being treated and is under control.

Side Effects

Muscle effects

Statins can occasionally cause inflammation (swelling) and damage to your muscles. Speak to your doctor if you experience muscle pain, tenderness or weakness that cannot be explained (for example, not due to physical work).
Your doctor will carry out a blood test to measure a substance in your blood called creatinine kinase (CK), which is released into the blood when your muscles are inflamed or damaged. If the level of CK in your blood is more than five times the normal level, your doctor will advise you to stop taking the statin. Once your CK level has returned to normal, your doctor may suggest you start taking the statin again, but at a lower dose.

Common side effects

Up to 1 in 10 people may experience the following:
  • gastrointestinal disorders, such as constipation, diarrhoea, dyspepsia (acid in the stomach) and flatulence (passing wind)
  • headache
  • insomnia (difficulty sleeping)
  • myalgia (pain in the muscles) and arthralgia (pain in the joints)
  • nausea (feeling sick)

Less common side effects

Up to 1 in 100 people may experience the following:
  • loss of appetite
  • myopathy (muscle damage)
  • peripheral neuropathy (loss of sensation or pain in the nerve endings of the hands and feet)
  • skin rash
  • vomiting (being sick)

Rare and very rare side effects

Between 1 in 1,000 and 1 in 10,000 people may experience the following:
  • dizziness
  • hepatitis (inflammation of the liver)
  • rhabdomyolysis, kidney damage caused by a substance caused myoglobin, which is released into the blood when a muscle is severely inflamed and damaged

Ability to drive

Statins are unlikely to affect your ability to drive. However, they may occasionally cause dizziness. If this affects you, do not drive.

Interactions with other Medicines

Interactions with food and Grapefruit Juice

  • Avoid drinking grapefruit juice if you are taking simvastatin. Grapefruit juice reduces the breakdown by the liver of simvastatin, which raises the level of simvastatin in the blood and makes you more likely to get side effects.
  • Atorvastatin interacts with grapefruit juice if you drink large quantities, but an occasional glass is thought to be safe. It is safe to drink grapefruit juice if you are taking any of the other statins.