Cholesterol is a fat. It made in the liver from the fatty foods that we eat, and plays a vital part in allowing the body to function normally, however too much of it is bad for us.
Cholesterol is carried in the blood by molecules called lipoproteins. There are several different lipoproteins, but the three main types are LDL (Bad cholesterol), HDL (Good Cholesterol) and Triglycerides. Low density lipoprotein (LDL) is thought to promote heart disease. It carries cholesterol from the liver to the cells and can cause a harmful build-up if there is too much for the cells to use. Recommended LDL level is below 3.37 mmol/l.
High density lipoprotein (HDL) is thought to prevent heart disease. It takes cholesterol away from the cells and back to the liver, where it is either broken down, or is passed from the body as a waste product. Recommended HDL range is 1.45 - 4 mmol/l. Triglycerides are another type of fatty substance present in the blood. They are found in dairy products, meat and cooking oils. Those who are overweight, have a diet that is high in fatty or sugary foods, or drink a large amount of alcohol, have an increased risk of having a high triglyceride level. Recommended Triglyceride level is below 1.71 mmol/l
The amount of total cholesterol present in the blood can range from 3.6 to 7.8 mmol/litre. A level above 6 mmol/litre is considered high, and a risk factor for arterial disease. A level of below 5.2 mmol/litre is recommended to prevent heart disease.
Evidence strongly indicates that high cholesterol levels can cause narrowing of the arteries (atherosclerosis), heart attacks, and strokes. The risk of coronary heart disease also rises as blood cholesterol levels increase. If other risk factors, such as high blood pressure and smoking, are present, the risk increases even more.
High cholesterol is symptomless but it leads to serious conditions, such as cardiovascular conditions (disease of the heart and blood vessels), angina, stroke, and mini-stroke, known as transient ischemic attack (TIA). A high level of cholesterol in your blood, together with a high level of triglycerides, can increase your risk of developing coronary heart disease.
Coronary heart disease is caused by narrowing of the arteries that supply the heart with blood. This narrowing of the arteries is called atherosclerosis. Fatty deposits, such as cholesterol, cellular waste products, calcium and other substances build up in the inner lining of an artery. This build up, known as plaque, usually affects small and medium sized arteries. The flow of blood through the arteries is restricted as the inside diameter is reduced and increases risk of blood clots.
A high cholesterol level may only be revealed if you have symptoms of atherosclerosis. These can include angina (caused by narrowed coronary arteries in the heart), leg pain on exercising (due to narrowing of the arteries that supply the lower limbs), blood clots and ruptured blood vessels (which can result in a stroke or mini-stroke), ruptured plaques (which can lead to a blood clot forming in one of the arteries delivering blood to the heart) and thick yellow patches around the eyes or elsewhere on the skin.
A number of different factors can contribute to high blood cholesterol. There are a number of preventable lifestyle-related risk factors that can increase your risk of developing high cholesterol. An unhealthy diet is a major factor. Some foods contain cholesterol (known as dietary cholesterol) for example, liver, kidneys and eggs. However, dietary cholesterol has little effect on blood cholesterol. More important is the amount of saturated fat in your diet. Foods that are high in saturated fat include red meat, meat pies, sausages, hard cheese, butter and lard, pastry, cakes and biscuits, and cream. Lack of exercise or physical activity increases your level of bad cholesterol (LDL), and reduces your level of good cholesterol (HDL). Obesity is another factor; if you are overweight you are likely to have an increased level of LDL and a decreased level of HDL. Drinking excessive amounts of alcohol increases cholesterol.
Other treatable risk factors which seriously increase your risk of cardiac death if not controlled (especially if you also suffer from cholesterol) include high blood pressure, diabetes, medical conditions, such as kidney and liver diseases, and an under-active thyroid gland and smoking.
Fixed risk factors
These are factors which you cannot influence. This includes a family history of heart disease or stroke. You are more likely to have high cholesterol if you have a close male relative (father or brother) aged under 55, or a female relative (mother or sister) aged under 65, who has been affected by cholesterol, coronary heart disease or stroke. Men are more at risk of having high blood cholesterol than women. The older you are, the greater the likelihood of having cholesterol problems and developing atherosclerosis. Early menopause in women also increases risk. People of certain ethnic groups including those of Indian, Pakistani, Bangladeshi, or Sri Lankan descent have an increased risk of high blood cholesterol.
Pharmacy Heart Screening
You can book our heart screening service at Whelehans Pharmacy Pearse St by calling us at 04493 34591. Screening takes less than half an hour and includes a check by our pharmacy team for blood pressure, cholesterol, blood glucose (diabetes) and body mass index. All this for only €20. Our screening takes place in a private consultation room. You will get a printout of your results.
To measure cholesterol, a simple blood test is often carried out. Before the test is done, you may be asked not to eat for 12 hours (usually including night time when you are asleep). This ensures that all food is completely digested and will not affect the outcome of the test. Your GP, or practice nurse, can carry out the blood test, and will take a sample either using a needle and a syringe, or by pricking your finger. We can also check total cholesterol for you in Whelehans Pharmacy. It is recommended that you have a total blood cholesterol level of less than 5.2mmol/litre, and an LDL cholesterol level of under 3.37mmol/litre. People with other risk factors for heart disease and cholesterol (as discussed last week) such as family history, obesity and high blood pressure (etc) should get their cholesterol checked regularly.
If you have been diagnosed with high cholesterol, the first method of treatment will usually involve making some changes to your diet (adopting a low fat diet), and ensuring that you take plenty of regular exercise. After a few months, if your cholesterol level has not dropped, you will usually be advised to take cholesterol lowering medication.
Ensuring that you have a healthy diet by changing to one that is low in saturated fats can reduce your level of LDL or bad cholesterol. If you are in a high risk category of getting cardiovascular disease, altering your diet will not lower your risk. However, eating a healthy, balanced diet has many other health-related benefits as well as reducing your cholesterol level. A healthy diet includes foods from all of the different food groups carbohydrates (cereals, wholegrain bread, potato, rice, pasta), proteins (for example, from lean meat, such as chicken and oily fish, like mackerel or sardines), and fats (varieties that are unsaturated, such as low fat mono- or poly-unsaturated spreads, and vegetable or sunflower oil). You should also eat at least five portions of a variety of different fruit and vegetables daily.
Cholesterol lowering medication
There are several different types of cholesterol lowering medication which work in different ways. Your GP will be able to advise you about the type of treatment that is most suitable for you.
Statins are the most commonly prescribed and generally most effective cholesterol lowering drug. Statins, such as simvastatin and atorvastatin, work by blocking the enzyme in your liver that is needed for making cholesterol. Statins are used to reduce your cholesterol to less than 4 mmol/l and your LDL cholesterol to less than 2 mmol/l. They are therefore useful in preventing and treating atherosclerosis which can cause chest pain, heart attacks, and strokes. Statins sometimes have mild side effects which can include constipation, diarrhea, headaches, and abdominal pain. In rarer cases, they can have more severe side effects such as muscle problems. I will discuss statins later in this article and in next week’s Westmeath Topic.
Aspirin may be recommended, depending on your age and a number of other factors. A low daily dose of aspirin (while it doesn’t lower cholesterol) can prevent blood clots from forming. Niacin is a B vitamin that is found in foods and in multi-vitamin supplements. In higher doses it may lower LDL (bad) cholesterol and raise HDL (good) cholesterol. Minor side effects include flushing or tingling skin, itching, and headaches. Other medications, such as cholesterol absorption inhibitors (ezetimibe), and bile-acid sequestrants, are also sometimes used to treat high cholesterol. However, they may be less effective than other forms of treatment and have more side effects.
More information on Statins
Statins are world’s most prescribed drugs and are used to reduce cholesterol. The reason statins are so popular is because heart disease is the world’s second biggest cause of death after cancer. Therefore, reducing cholesterol if high will greatly reduce the risk of heart disease and death. In Ireland in 2000, heart disease was the leading cause of death being responsible for 41% of all deaths.
There are several types of statins on the market, but they all work in the same way. Examples of statins available on the market and their brand names are Atorvastatin (eg. Lipitor®, Atorvas), Pravastatin (eg. Lipostat®, Pravatin®), Rosuvastatin (eg. Crestor®, Rosuva®) and Simvastatin (eg. Zocor®, Inegy®, Sivatin®). Statins are only available with doctor’s prescription in Ireland. However, simvastatin has recently become available over the counter in pharmacies in the UK; however they are sold under strict guidelines. Clinical trials show that statins are very effective at reducing cholesterol and hence heart disease. Statins are one of the major reasons for the significant fall in death rate from heart disease in Ireland over the last 20 years. Statins work by blocking the enzyme HMG-CoA reductase, which plays an important role in the production of cholesterol in the liver. They are therefore useful in preventing and treating atherosclerosis (blockage of coronary arteries) which can cause chest pain, heart attacks, strokes and cardiac deaths.
Statins are world’s most prescribed drugs and are used to reduce cholesterol. Most statins must be taken at night, as most cholesterol is made while we sleep. In fact, the only statin which does not have to be taken at night is atorvastatin, which can be taken morning or night. Statins are more effective in reducing LDL cholesterol than other cholesterol medication. However, they are less effective than fibrates in reducing triglycerides. Fibrates are another type of cholesterol lowering medicines which are not used as often as statins. They are more associated with gastrointestinal side effects such as nausea (eg) gemfibrozil (Lopid®). Other non-statin drugs used to lower cholesterol include ezetimibe (Ezetrol®) which reduces the absorption of cholesterol and is used instead of a statin if a statin is not tolerated or in addition to a statin if a statin is not reducing cholesterol sufficiently. There is some evidence that omega 3 supplements (though they are no longer allowed on the medical card or drug payment scheme) lower triglycerides and are often added to statin therapy when triglycerides are high.
How effective are statins?
A study published in the British Medical Journal in 2003 showed that on average, statins reduce LDL cholesterol by 1.8 mmol/litre. This resulted in a 60% reduction in the risk of cardiovascular events such as heart attacks, clots and sudden cardiac death and a 17% reduction in the risk of stroke.
Which statin is best?
There is no major study to show which statin is most effective. However the CURVEs study in America in 1998 showed that atorvastatin is more effective than other statins at lowering cholesterol. However, another study published in the American Heart Journal in 2006 showed that there was no significant difference between atorvastatin and other statins (simvastatin and pravastatin) at reducing heart disease.
Who should be prescribed statins?
In Ireland, over 20% of adults are at risk of coronary heart disease due to high cholesterol. There is some controversy on who should be prescribed statins. The general guideline for people who have no previous heart problems is that they should be used if cholesterol is high (over 6mmol/litre) and a there is a cardiovascular risk of greater than 20% over the next 10 years. Your cardiovascular risk over 10 years is your risk of having any cardiovascular event such as stroke or heart attack over the next 10 years. It depends on many factors such as your age, sex, weight, blood pressure, cholesterol, family history of heart disease, whether you smoke or are diabetic. Your doctor can calculate your cardiovascular risk.
For those who have already suffered a cardiovascular event such as a stroke, statins are recommended if total cholesterol is over 3.5mmol/l. Guidelines state that they should be considered in all diabetic patients over 40. Statins are very frequently prescribed in the elderly as elderly patients generally have a higher risk of heart disease.
Like all medication, statins can cause side effects. The most serious side effect of statins is a muscle complaint called myalgia. It is characterised by muscle pain and weakness. If it occurs the statin should be stopped as it can lead to a potentially fatal condition called rhabdomyolysis. It is estimated that one in 1000 people using statins may suffer from myalgia and one in 10,000 may suffer from rhabdomyolysis. You should report to your doctor immediately if you suffer from muscle pain, tenderness or weakness while taking a statin. Statins can also raise liver enzymes which can lead to liver problems. It is very important that doctors do a liver function test for those starting statins. Current guidelines are to get a liver function test before starting a statin, 3 months after starting and again after 12 months.
Gastrointestinal effects (nausea, indigestion, constipation, diarrhoea and flatulence) are the most common side effects of statins. Headache, dizziness and rash occur less frequently. Sleep disturbance can occur, although it seems to be more of a problem with simvastatin and atorvastatin. The good news is that the majority of people who take statins have no problems and they are proven to save lives by preventing heart disease. All statins now have equally effective but less expensive generic equivalents available. Whelehans stock all these generics which can give you significant savings. Always ask your pharmacist for the generic version.
Preventing Side Effects
Statins reduce Co Enzyme Q10, a vital nutrient in almost every cell of the body. Reduction in the level of Co-enzyme Q10 is a reason for many of the side effects of statins. Whelehans own brand Co Enzyme Q10 contains 100mg of Co Enzyme Q10. It may help prevent side effects of statins such as headaches, tired aching muscles, muscle cramps and general fatigue. If you currently take a statin and experience a side effect such as headache, I would advise trying Co Enzyme Q10. I have seen Co Enzyme Q10 stop the side effects of statins in some people. Whelehans own brand Co Enzyme Q10 is an affordable option and unlike many Co Enzyme Q10 supplements, it only needs to be taken once daily (Price €14.99).
Disclaimer: Please ensure you consult with your healthcare professional before making any changes recommended
For comprehensive and free health advice and information call in to Whelehans Pharmacies, log on to www.whelehans.ie or dial 04493 34591 (Pearse St) or 04493 10266 (Clonmore).