Friday, 31 August 2007
Sunday, 19 August 2007
you've got to work up a sweat
reposted from Guardian
Polly Curtis, health correspondent
Friday August 17, 2007
The Guardian
The era of gentle exercise is over. It's official: you've got to work up a sweat
Polly Curtis, health correspondent
Friday August 17, 2007
The Guardian
 |  Runners in the London Marathon. Adults are now being told they need regular vigorous exercise. Photograph: Rebecca Naden |
Official advice that 30 minutes of gentle exercise a day is enough to improve your health has been revised by the scientists who first developed the international fitness guidelines.
The scientists, world-leaders in public health and exercise advice, say they want to clarify the fitness guidelines for healthy adults which were adopted by the World Health Organisation and later used as a template for healthy living by the UK government. Some people have misunderstood the original message and are doing too little exercise, they argue. But they go even further saying explicitly that people should do vigorous as well as moderate aerobic exercise because of the "substantial science base" that it is good for you.Until now, government recommendations have suggested that people can achieve a minimum level of fitness through their normal daily routines. But amid fears that the lightest of activities such as dusting and the stroll to the car are being counted as exercise, a new study by the public health experts behind the formula concludes adults need to add jogging and twice-weekly weight training sessions if they want to cut their risk of heart disease and obesity.
The paper published in Circulation, the journal of the American Heart Association, includes authors who are influential members of the American College of Sports Medicine. They write: "There are people who have not accepted, and others who have misinterpreted, the original recommendation. Some people continue to believe that only vigorous intensity activity will improve health while others believe that the light activities of their daily lives are sufficient to promote health."
The new guidelines say:
· 30 minutes of moderate exercise a day is still the minimum, but vigorous as opposed to moderate activity should be "explicitly" recommended
· Combining days of moderate exercise with other days of vigorous exercise is better for you
· Moderate exercise should be in addition to daily activities such as casual walking, shopping or taking out the rubbish
· People should do two weight-training sessions a week
· Adults over 65 or those who are infirm during their 50s and early 60s should also do balancing exercises if they are at risk of falling and draw up appropriate exercise plans with their doctors.
"Many adults, including those who wish to improve their personal fitness or further reduce their risk of premature chronic health conditions and mortality related to physical inactivity, should exceed the minimum recommended amounts of physical activity," it says.
But their apparent change of heart exposes the dilemma facing health officials of how to encourage an increasingly overweight population to exercise without deterring them with over-ambitious programmes. Anti-obesity experts suggested that advising people to do weight-training was unrealistic.
David Haslam, chair of the National Obesity Forum, said: "If you suggested everyone here should do weight-training twice a week they wouldn't do it. They don't have the time or money for the gym, it would be an unrealistic guideline. I'd rather see healthy habits built into daily life - gyms aren't a sustainable habit."
Paul Gately, professor of exercise and obesity at Leeds Metropolitan University, said: "Scientists keep changing the goalposts but this advice is trying to provide more specific information for specific groups of people to encourage them to do appropriate exercise.
"It's the age-old problem of one-size-fits-all public health advice versus tailored programmes. People who are very overweight would have to do an hour of exercise a day just to maintain their weight if they aren't going to change their diets."
The authors include several experts who are on a high-level committee in the US which next year will announce America's new physical activity guidelines. Their revisions this month are widely expected to be adopted as official advice there. Their original recommendations in 1995 were quickly adopted by the WHO and by the UK government in 1996.
In 2004 the chief medical officer for England and Wales, Sir Liam Donaldson, republished the recommendations in his attempt to underscore the importance of more rigorous exercise and show that people could achieve the total through smaller 10-minute chunks. It was revealed then that up to two-thirds of men and three-quarters of women were failing to meet the 30-minute goal. Scotland's advice is similar to that in England and Wales.
A spokeswoman for the Department of Health said it was watching developments in the evidence about how much exercise was optimum but there were no plans at the moment to change the advice.
keep pace with the constantly changing advice on how much exercise is healthy.
reposted from Guardian
No Sweat. Never mind jogging, I can't keep pace with the constantly changing advice on how much exercise is healthy.
He can work it out: Tim Dowling being himself, only better. Photograph: David Levene.
Now they tell us: the scientists who developed the fitness guidelines for adults, the guidelines adopted by the World Health Organisation, have decided to "clarify" their advice. They would like to point out that when they where they said "moderate" exercise, they meant "vigorous", and that where they implied that a minimum level of fitness could be maintained through one's normal daily routines, they now wish to include "in addition jogging and two weight-training sessions a week". If you're not regularly breaking a sweat, they say, you're not doing enough.
This new advice come just days after the release of a study that said that even low levels of physical activity - say, three brisk walks a week - could lower the risk of heart disease in people who took no other exercise. What are we supposed to believe?
In hindsight, the old guidelines always seemed too good to be true. To suggest that doing the hoovering and using the stairs counted as exercise was to give almost everybody the idea that they were already immensely fit. People could congratulate themselves for simply negotiating the dull routine of daily existence. I had taken to including the sweat I broke into whenever a tax demand arrived as part of my overall exercise regime.
Everybody knows that maintaining fitness involves a certain amount of bother, and that improving fitness requires a degree of discomfort. If you're only walking between the sofa and the fridge, you're better off not exercising at all.
Perhaps the health officials have they taken their revisions a little too far. How many minimally fit people have been reclassified as dangerously unfit by this shift in emphasis? Lots of us do a bit of regular, actual exercise - beyond the realm of vigorous ironing or trudging to the bus stop - but how many of us do two weight-training sessions a week? I've done two weight-training sessions full stop, and it seemed like more than enough to me.
But then I don't have to worry about fitness, because I lift myself out of the bath every day, rain or shine.
Friday, 9 February 2007
The evidence I've considered for Statin treatment - to reduce cholesterol & risk of Cardiovascular disease
this blog copied in full from my crabsallover blog February 2007.
This week SIGN (Scottish Intercollegiate Guidelines Network) published Guideline No 97 - Risk estimation and prevention of Cardiovascular Disease (CVD):-
Coronary Heart Disease (CHD) is a disease of the heart and coronary arteries caused by a build of fatty materials in the blood vessels which supply the heart with oxygen. This can cause a heart attack, or chest pain or angina.
My risk of CVD in the next 10 years is 1 in 12.5 (8%) according to my 'ASSIGN' score (table 1). So for every 1000 persons with my CVD risk, 80 will have a CVD event in the next 10 years.
Other Factors - not accounted for by 'ASSIGN' score
In October 2006 my blood tests were:
The report defines people in a 'High Risk' category if they have a >=20% risk of CVD over the next 10 years. For those with 1% annual risk of CVD ( viz. 10% over 10 years) benefits have been shown using statins (3-Hydroxy-3-Methylglutaryl-CoA (HMG-CoA) Reductase inhibitors). Annual CVD is 1% in USA and Europe. So most middle aged men and women could benefit from a statin and CVD reduction. (Full Guideline (FG) 2.4 pg 11) 8.2 Aspirin Antiplatelet therapy with Aspirin reduces Myocardial Infarction (heart attack) risk but increases stroke and major gastrointestinal bleeding risk. P S Sanmuganathan et al in Heart85:265-271 2001; concluded "Aspirin treatment for primary prevention is safe and worthwhile at coronary event risk greater than 1.5%/year; safe but of limited value at coronary risk 1%/year; and unsafe at coronary event risk 0.5%/year." With my 8% over 10 year CVD risk, Aspirin is of limited value or unsafe. 9 Lipid Lowering Low density Lipoprotein (LDL) makes up 60-70% of serum cholesterol. The Friedwald equation LDL = TC-HDL-(TG/2.2) (9.2 pg 32) Statins reduce Total Cholesterol TC by approx. 20% or 1mmol and LDL Cholesterol by 30% (9.3, pg 28) with a 30% reduction in CHD mortality (9.3 pg 29). 
With each doubling of the dose of a statin LDL levels fall by 6%. A reduction of 1.6 mmol/l halves the risk of CHD events after 2 years and this reduction can be achieved with standard doses of statins. (9.4 pg 30, table 8) My 8% (1 in 12.5) risk of CVD (table 1, total cholesterol 5.1 mmol/l) could be reduced to a 6% risk (1 in 17) (table 2, total cholesterol 3.88 mmol/l) - a 25% risk reduction. 80 people per thousand, like me, will have CardioVascular Disease over 10 years. By taking Statins that risk is reduced to 60 people with CVD. Mild muscle pains or other adverse effects (eg fever, malaise) may require reduction in statin levels or change of statin type whilst severe side effects will require statin therapy to be discontinued. (para 9.6, pg 36). Current NHS target for individuals at high cardiovascular risk is a TC level of less than 5 mmol. Reducing this target to 4.5 or 4.0 mmol/l would have major resource implications for NHS (9.7 pg 32). Zocor (simvastatin, 10mg per day) is available from Boots over the counter for £8 per month. HDL Cholesterol my level of 1.02 mmol/l HDL Cholesterol is low and may require treatment with Fibrates (raises levels 10-15%,) (9.10.2 pg 39) or Nicotinic Acid (raises levels 15-35%) (9.10.3 pg 40) 9.8 Safety of Statins Statins are safe. No increase in cancer levels has been found. Raised levels of liver enzymes (aspartate and alanine aminotransferase) occur in 1% cases which is completely reversible when treatment is withdrawn. Minor muscle discomfort is common though the incidence varies. Rare more serious Myopathy with raised creatine kinase occurs in 0.1% cases. In 0.01% cases Rhabdomyalysis (renal failure) occurs. Withdrawal of treatment leads to recovery in a majority of cases but death can occur if patient is receiving several drug treatments or experiencing multiple symptoms. Statins may possibly interact with other medications eg fibrates (niacin, nicotinic acid). Inhibitors of cytochrome P450 and grapefruit juice may increase Myopathy risk. Atorvastatin, fluvastatin, pravastatin, rosuvastatin and simvastatin are licensed for use in UK. Annex 2 pg 62 Joint British Societies (JBS2 - reference 28) proposed total cholesterol target of <4mmol/l size="4">Annex 3 pg 65 Creatine Kinase (CK) baseline pretreatment level might be useful to monitor possible muscular symptoms. Annex 4 pg 66 Liver transaminase levels advisable prior to statin treatment, 3 months after treatment and when dose level is increased. This indicates potential for jaundice, malaise, fatigue, lethargy etc. Annex 5 pg 67 Assessment of renal function is advisable before starting statin therapy. Test for serum creatinine and proteinuria. Conclusions for my health
Table 1: Baseline 8% risk 
Table 2: 6% risk after Statin treatment 
Table 3: 5% risk after treatment to give medium HDL cholesterol levels 
Table 4: 4% risk after treatment to give high HDL cholesterol levels 
Table 5: 3% risk after treatment to give low blood pressure
This week SIGN (Scottish Intercollegiate Guidelines Network) published Guideline No 97 - Risk estimation and prevention of Cardiovascular Disease (CVD):-
- Full Guideline (this review references this booklet)
- Patient Guideline
- Quick Reference Guide
- Costs and Resources to implement in Scotland
Coronary Heart Disease (CHD) is a disease of the heart and coronary arteries caused by a build of fatty materials in the blood vessels which supply the heart with oxygen. This can cause a heart attack, or chest pain or angina.
My risk of CVD in the next 10 years is 1 in 12.5 (8%) according to my 'ASSIGN' score (table 1). So for every 1000 persons with my CVD risk, 80 will have a CVD event in the next 10 years.
Other Factors - not accounted for by 'ASSIGN' score
- At 102cm I have borderline abdominal obesity (defined as greater or equal to 102cm waist measurement in men). (4.7 pg 15)
- waist hip ratio is 102cm/98cm = 1.04 (<0.95>
- I'm overweight BMI >25 (12st 6 pounds, height 5'7.5", BMI 27.5).
In October 2006 my blood tests were:
- 5.1 mmol/l total cholesterol (NHS normal: <=5.0)
- 3.0 mmol/l LDL 'bad' cholesterol
- 1.02 mmol/l HDL 'good' cholesterol (normal >1.03) (4.7 pg 15)
- total cholesterol/HDL cholesterol ratio = 5.0
- Blood pressure = 130 systolic/70 diastolic (normal <130/85)
- On 30th April 2007 my figure (ex Poole Hospital 110/70)
- 5.9 mmol /l glucose
The report defines people in a 'High Risk' category if they have a >=20% risk of CVD over the next 10 years. For those with 1% annual risk of CVD ( viz. 10% over 10 years) benefits have been shown using statins (3-Hydroxy-3-Methylglutaryl-CoA (HMG-CoA) Reductase inhibitors). Annual CVD is 1% in USA and Europe. So most middle aged men and women could benefit from a statin and CVD reduction. (Full Guideline (FG) 2.4 pg 11) 8.2 Aspirin Antiplatelet therapy with Aspirin reduces Myocardial Infarction (heart attack) risk but increases stroke and major gastrointestinal bleeding risk. P S Sanmuganathan et al in Heart85:265-271 2001; concluded "Aspirin treatment for primary prevention is safe and worthwhile at coronary event risk greater than 1.5%/year; safe but of limited value at coronary risk 1%/year; and unsafe at coronary event risk 0.5%/year." With my 8% over 10 year CVD risk, Aspirin is of limited value or unsafe. 9 Lipid Lowering Low density Lipoprotein (LDL) makes up 60-70% of serum cholesterol. The Friedwald equation LDL = TC-HDL-(TG/2.2) (9.2 pg 32) Statins reduce Total Cholesterol TC by approx. 20% or 1mmol and LDL Cholesterol by 30% (9.3, pg 28) with a 30% reduction in CHD mortality (9.3 pg 29). 
With each doubling of the dose of a statin LDL levels fall by 6%. A reduction of 1.6 mmol/l halves the risk of CHD events after 2 years and this reduction can be achieved with standard doses of statins. (9.4 pg 30, table 8) My 8% (1 in 12.5) risk of CVD (table 1, total cholesterol 5.1 mmol/l) could be reduced to a 6% risk (1 in 17) (table 2, total cholesterol 3.88 mmol/l) - a 25% risk reduction. 80 people per thousand, like me, will have CardioVascular Disease over 10 years. By taking Statins that risk is reduced to 60 people with CVD. Mild muscle pains or other adverse effects (eg fever, malaise) may require reduction in statin levels or change of statin type whilst severe side effects will require statin therapy to be discontinued. (para 9.6, pg 36). Current NHS target for individuals at high cardiovascular risk is a TC level of less than 5 mmol. Reducing this target to 4.5 or 4.0 mmol/l would have major resource implications for NHS (9.7 pg 32). Zocor (simvastatin, 10mg per day) is available from Boots over the counter for £8 per month. HDL Cholesterol my level of 1.02 mmol/l HDL Cholesterol is low and may require treatment with Fibrates (raises levels 10-15%,) (9.10.2 pg 39) or Nicotinic Acid (raises levels 15-35%) (9.10.3 pg 40) 9.8 Safety of Statins Statins are safe. No increase in cancer levels has been found. Raised levels of liver enzymes (aspartate and alanine aminotransferase) occur in 1% cases which is completely reversible when treatment is withdrawn. Minor muscle discomfort is common though the incidence varies. Rare more serious Myopathy with raised creatine kinase occurs in 0.1% cases. In 0.01% cases Rhabdomyalysis (renal failure) occurs. Withdrawal of treatment leads to recovery in a majority of cases but death can occur if patient is receiving several drug treatments or experiencing multiple symptoms. Statins may possibly interact with other medications eg fibrates (niacin, nicotinic acid). Inhibitors of cytochrome P450 and grapefruit juice may increase Myopathy risk. Atorvastatin, fluvastatin, pravastatin, rosuvastatin and simvastatin are licensed for use in UK. Annex 2 pg 62 Joint British Societies (JBS2 - reference 28) proposed total cholesterol target of <4mmol/l size="4">Annex 3 pg 65 Creatine Kinase (CK) baseline pretreatment level might be useful to monitor possible muscular symptoms. Annex 4 pg 66 Liver transaminase levels advisable prior to statin treatment, 3 months after treatment and when dose level is increased. This indicates potential for jaundice, malaise, fatigue, lethargy etc. Annex 5 pg 67 Assessment of renal function is advisable before starting statin therapy. Test for serum creatinine and proteinuria. Conclusions for my health - current risk of CVD is 8% - table 1
- Aspirin is of limited value or unsafe
- Statins are safe and should be taken daily after
- a baseline checkup (total cholesterol, LDL, HDL, Triglycerides, blood pressure, Creatine Kinase, liver transaminase, serum creatinine and proteinuria)
- Statin treatment targets
- 30% reduction in LDL cholesterol (from 3 to 1.9 mmol/l)
- 24% reduction in total cholesterol (from 5.1 to 3.88 mmol/l)
- reduce risk of CVD by 25% - from 1 in 12 (8%) to 1 in 17 (6%) over 10 years - table 2.
- Fibrates or Nicotinic acid treatment targets (after initial statin treatment)
- Reduce CVD risk to 5% (1 in 20) by increasing HDL cholesterol to medium levels (1.34 mmol/l) - table 3
- Reduce CVD risk to 4% (1 in 25) by increasing HDL cholesterol to high levels (1.73 mmol/l) - table 4
- Reduce CVD risk to 3% (1 in 33) by reducing systolic blood pressure from 130 to 108 mmHg by improving diet and increasing exercise - table 5
Table 1: Baseline 8% risk 
Table 2: 6% risk after Statin treatment 
Table 3: 5% risk after treatment to give medium HDL cholesterol levels 
Table 4: 4% risk after treatment to give high HDL cholesterol levels 
Table 5: 3% risk after treatment to give low blood pressure
The evidence I've considered for Statin treatment - to reduce cholesterol & risk of Cardiovascular disease
This week SIGN (Scottish Intercollegiate Guidelines Network) published Guideline No 97 - Risk estimation and prevention of Cardiovascular Disease (CVD):-
Coronary Heart Disease (CHD) is a disease of the heart and coronary arteries caused by a build of fatty materials in the blood vessels which supply the heart with oxygen. This can cause a heart attack, or chest pain or angina.
My risk of CVD in the next 10 years is 1 in 12.5 (8%) according to my 'ASSIGN' score (table 1). So for every 1000 persons with my CVD risk, 80 will have a CVD event in the next 10 years.
Other Factors - not accounted for by 'ASSIGN' score
In October 2006 my blood tests were:
The report defines people in a 'High Risk' category if they have a >=20% risk of CVD over the next 10 years. For those with 1% annual risk of CVD ( viz. 10% over 10 years) benefits have been shown using statins (3-Hydroxy-3-Methylglutaryl-CoA (HMG-CoA) Reductase inhibitors). Annual CVD is 1% in USA and Europe. So most middle aged men and women could benefit from a statin and CVD reduction. (Full Guideline (FG) 2.4 pg 11) 8.2 Aspirin Antiplatelet therapy with Aspirin reduces Myocardial Infarction (heart attack) risk but increases stroke and major gastrointestinal bleeding risk. P S Sanmuganathan et al in Heart85:265-271 2001; concluded "Aspirin treatment for primary prevention is safe and worthwhile at coronary event risk greater than 1.5%/year; safe but of limited value at coronary risk 1%/year; and unsafe at coronary event risk 0.5%/year." With my 8% over 10 year CVD risk, Aspirin is of limited value or unsafe. 9 Lipid Lowering Low density Lipoprotein (LDL) makes up 60-70% of serum cholesterol. The Friedwald equation LDL = TC-HDL-(TG/2.2) (9.2 pg 32) Statins reduce Total Cholesterol TC by approx. 20% or 1mmol and LDL Cholesterol by 30% (9.3, pg 28) with a 30% reduction in CHD mortality (9.3 pg 29). With each doubling of the dose of a statin LDL levels fall by 6%. A reduction of 1.6 mmol/l halves the risk of CHD events after 2 years and this reduction can be achieved with standard doses of statins. (9.4 pg 30, table 8) My 8% (1 in 12.5) risk of CVD (table 1, total cholesterol 5.1 mmol/l) could be reduced to a 6% risk (1 in 17) (table 2, total cholesterol 3.88 mmol/l) - a 25% risk reduction. 80 people per thousand, like me, will have CardioVascular Disease over 10 years. By taking Statins that risk is reduced to 60 people with CVD. Mild muscle pains or other adverse effects (eg fever, malaise) may require reduction in statin levels or change of statin type whilst severe side effects will require statin therapy to be discontinued. (para 9.6, pg 36). Current NHS target for individuals at high cardiovascular risk is a TC level of less than 5 mmol. Reducing this target to 4.5 or 4.0 mmol/l would have major resource implications for NHS (9.7 pg 32). Zocor (simvastatin, 10mg per day) is available from Boots over the counter for £8 per month. HDL Cholesterol my level of 1.02 mmol/l HDL Cholesterol is low and may require treatment with Fibrates (raises levels 10-15%,) (9.10.2 pg 39) or Nicotinic Acid (raises levels 15-35%) (9.10.3 pg 40) 9.8 Safety of Statins Statins are safe. No increase in cancer levels has been found. Raised levels of liver enzymes (aspartate and alanine aminotransferase) occur in 1% cases which is completely reversible when treatment is withdrawn. Minor muscle discomfort is common though the incidence varies. Rare more serious Myopathy with raised creatine kinase occurs in 0.1% cases. In 0.01% cases Rhabdomyalysis (renal failure) occurs. Withdrawal of treatment leads to recovery in a majority of cases but death can occur if patient is receiving several drug treatments or experiencing multiple symptoms. Statins may possibly interact with other medications eg fibrates (niacin, nicotinic acid). Inhibitors of cytochrome P450 and grapefruit juice may increase Myopathy risk. Atorvastatin, fluvastatin, pravastatin, rosuvastatin and simvastatin are licensed for use in UK. Annex 2 pg 62 Joint British Societies (JBS2 - reference 28) proposed total cholesterol target of <4mmol/l size="4">Annex 3 pg 65 Creatine Kinase (CK) baseline pretreatment level might be useful to monitor possible muscular symptoms. Annex 4 pg 66 Liver transaminase levels advisable prior to statin treatment, 3 months after treatment and when dose level is increased. This indicates potential for jaundice, malaise, fatigue, lethargy etc. Annex 5 pg 67 Assessment of renal function is advisable before starting statin therapy. Test for serum creatinine and proteinuria. Conclusions for my health
Table 1: Baseline 8% risk Table 2: 6% risk after Statin treatment Table 3: 5% risk after treatment to give medium HDL cholesterol levels Table 4: 4% risk after treatment to give high HDL cholesterol levels
Table 5: 3% risk after treatment to give low blood pressure
- Full Guideline (this review references this booklet)
- Patient Guideline
- Quick Reference Guide
- Costs and Resources to implement in Scotland
Coronary Heart Disease (CHD) is a disease of the heart and coronary arteries caused by a build of fatty materials in the blood vessels which supply the heart with oxygen. This can cause a heart attack, or chest pain or angina.
My risk of CVD in the next 10 years is 1 in 12.5 (8%) according to my 'ASSIGN' score (table 1). So for every 1000 persons with my CVD risk, 80 will have a CVD event in the next 10 years.
Other Factors - not accounted for by 'ASSIGN' score
- At 102cm I have borderline abdominal obesity (defined as greater or equal to 102cm waist measurement in men). (4.7 pg 15)
- waist hip ratio is 102cm/98cm = 1.04 (<0.95>
- I'm overweight BMI >25 (12st 6 pounds, height 5'7.5", BMI 27.5).
In October 2006 my blood tests were:
- 5.1 mmol/l total cholesterol (NHS normal: <=5.0)
- 3.0 mmol/l LDL 'bad' cholesterol
- 1.02 mmol/l HDL 'good' cholesterol (normal >1.03) (4.7 pg 15)
- total cholesterol/HDL cholesterol ratio = 5.0
- Blood pressure = 130 systolic/70 diastolic (normal <130/85)
- On 30th April 2007 my figure (ex Poole Hospital 110/70)
- 5.9 mmol /l glucose
The report defines people in a 'High Risk' category if they have a >=20% risk of CVD over the next 10 years. For those with 1% annual risk of CVD ( viz. 10% over 10 years) benefits have been shown using statins (3-Hydroxy-3-Methylglutaryl-CoA (HMG-CoA) Reductase inhibitors). Annual CVD is 1% in USA and Europe. So most middle aged men and women could benefit from a statin and CVD reduction. (Full Guideline (FG) 2.4 pg 11) 8.2 Aspirin Antiplatelet therapy with Aspirin reduces Myocardial Infarction (heart attack) risk but increases stroke and major gastrointestinal bleeding risk. P S Sanmuganathan et al in Heart85:265-271 2001; concluded "Aspirin treatment for primary prevention is safe and worthwhile at coronary event risk greater than 1.5%/year; safe but of limited value at coronary risk 1%/year; and unsafe at coronary event risk 0.5%/year." With my 8% over 10 year CVD risk, Aspirin is of limited value or unsafe. 9 Lipid Lowering Low density Lipoprotein (LDL) makes up 60-70% of serum cholesterol. The Friedwald equation LDL = TC-HDL-(TG/2.2) (9.2 pg 32) Statins reduce Total Cholesterol TC by approx. 20% or 1mmol and LDL Cholesterol by 30% (9.3, pg 28) with a 30% reduction in CHD mortality (9.3 pg 29). With each doubling of the dose of a statin LDL levels fall by 6%. A reduction of 1.6 mmol/l halves the risk of CHD events after 2 years and this reduction can be achieved with standard doses of statins. (9.4 pg 30, table 8) My 8% (1 in 12.5) risk of CVD (table 1, total cholesterol 5.1 mmol/l) could be reduced to a 6% risk (1 in 17) (table 2, total cholesterol 3.88 mmol/l) - a 25% risk reduction. 80 people per thousand, like me, will have CardioVascular Disease over 10 years. By taking Statins that risk is reduced to 60 people with CVD. Mild muscle pains or other adverse effects (eg fever, malaise) may require reduction in statin levels or change of statin type whilst severe side effects will require statin therapy to be discontinued. (para 9.6, pg 36). Current NHS target for individuals at high cardiovascular risk is a TC level of less than 5 mmol. Reducing this target to 4.5 or 4.0 mmol/l would have major resource implications for NHS (9.7 pg 32). Zocor (simvastatin, 10mg per day) is available from Boots over the counter for £8 per month. HDL Cholesterol my level of 1.02 mmol/l HDL Cholesterol is low and may require treatment with Fibrates (raises levels 10-15%,) (9.10.2 pg 39) or Nicotinic Acid (raises levels 15-35%) (9.10.3 pg 40) 9.8 Safety of Statins Statins are safe. No increase in cancer levels has been found. Raised levels of liver enzymes (aspartate and alanine aminotransferase) occur in 1% cases which is completely reversible when treatment is withdrawn. Minor muscle discomfort is common though the incidence varies. Rare more serious Myopathy with raised creatine kinase occurs in 0.1% cases. In 0.01% cases Rhabdomyalysis (renal failure) occurs. Withdrawal of treatment leads to recovery in a majority of cases but death can occur if patient is receiving several drug treatments or experiencing multiple symptoms. Statins may possibly interact with other medications eg fibrates (niacin, nicotinic acid). Inhibitors of cytochrome P450 and grapefruit juice may increase Myopathy risk. Atorvastatin, fluvastatin, pravastatin, rosuvastatin and simvastatin are licensed for use in UK. Annex 2 pg 62 Joint British Societies (JBS2 - reference 28) proposed total cholesterol target of <4mmol/l size="4">Annex 3 pg 65 Creatine Kinase (CK) baseline pretreatment level might be useful to monitor possible muscular symptoms. Annex 4 pg 66 Liver transaminase levels advisable prior to statin treatment, 3 months after treatment and when dose level is increased. This indicates potential for jaundice, malaise, fatigue, lethargy etc. Annex 5 pg 67 Assessment of renal function is advisable before starting statin therapy. Test for serum creatinine and proteinuria. Conclusions for my health - current risk of CVD is 8% - table 1
- Aspirin is of limited value or unsafe
- Statins are safe and should be taken daily after
- a baseline checkup (total cholesterol, LDL, HDL, Triglycerides, blood pressure, Creatine Kinase, liver transaminase, serum creatinine and proteinuria)
- Statin treatment targets
- 30% reduction in LDL cholesterol (from 3 to 1.9 mmol/l)
- 24% reduction in total cholesterol (from 5.1 to 3.88 mmol/l)
- reduce risk of CVD by 25% - from 1 in 12 (8%) to 1 in 17 (6%) over 10 years - table 2.
- Fibrates or Nicotinic acid treatment targets (after initial statin treatment)
- Reduce CVD risk to 5% (1 in 20) by increasing HDL cholesterol to medium levels (1.34 mmol/l) - table 3
- Reduce CVD risk to 4% (1 in 25) by increasing HDL cholesterol to high levels (1.73 mmol/l) - table 4
- Reduce CVD risk to 3% (1 in 33) by reducing systolic blood pressure from 130 to 108 mmHg by improving diet and increasing exercise - table 5
Table 1: Baseline 8% risk Table 2: 6% risk after Statin treatment Table 3: 5% risk after treatment to give medium HDL cholesterol levels Table 4: 4% risk after treatment to give high HDL cholesterol levels Table 5: 3% risk after treatment to give low blood pressure
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