The “new” cholesterol guidelines – what’s really the issue?

For decades people and doctors have been obsessed with cholesterol levels.  Books have been written, diets promoted, medications prescribed – all with the purpose of getting your cholesterol to “goal”.  You get your labs done and your doctor tells you your cholesterol is high.  You are instructed to eat a low-fat diet, exercise more and possibly start a medication.  Often you are not sure which numbers are high, or what they mean.  But you know that high cholesterol is a bad thing, and so you try to follow the doctor’s advice and lower your cholesterol.  
11/12/13 was a unique date – not only the second to last sequential month/day/year in our lifetimes; it is also the day the American College of Cardiology (ACC) and American Heart Association (AHA) released new guidelines for cholesterol management that recommend treating high cholesterol but not to any specific number.
This represents a change in over a decade of “goal oriented” recommendations which specified a level of bad cholesterol (LDL) to aim for, using multiple medications if needed to get there.
New Guidelines for Cholesterol:
  • Aim for cholesterol to be reduced by half
  • Only use a statin medication
  • Not necessary to add other medications if you don’t get quite there
Why were these changes recommended?
The theory behind the changes is that the guideline committee felt there wasn’t strong enough evidence supporting a specific target.  For example, if a person’s LDL cholesterol is reduced from 195 to 95, is there any real additional benefit in getting to the previous high risk goal of 70? Or is 95 good enough?
So what are the recommendations?
People are broken down into 2 risk groups in terms of deciding if a statin should be used
  1. High Risk:  people with a prior heart attack, bypass surgery, a stent or diabetes should take statins.  Statins are also recommended for those with very high LDL cholesterol (>190)
  2. Future Risk:  those whose 10 year risk of a heart attack is 7.5% or greater.  This number is calculated with a risk calculator that uses cholesterol, weight, blood pressure, smoking and other factors to come up with your number.
The High Risk group is not a  major change in terms of starting treatment.  The change is not recommending a target value for the LDL cholesterol.
The Future Risk group is different – the previous recommendations used a higher 10 year risk 15-20% before starting a statin.
Besides statin therapy, lifestyle changes are a cornerstone of the new recommendations:
  • No smoking
  • A health body weight
  • Exercise
  • A diet with lots of vegetables, fruits and lean protein
Controversy
Not all doctors agree that the 10-year risk is the best guide for starting treatment – why not lifetime risk?  There also have been questions about the risk calculator itself – the formula used appears to overestimate risk – including more people needing treatment than may truly benefit.  In addition, several of the members of the guideline committee quit due to disagreement on the direction the committee was going with their recommendations.  The remaining committee members only considered evidence from very specific types of trials, ignoring other trials that made compelling arguments but did not meet their standard of evidence.  The committee also chose not to include other markers of cardiovascular disease such as LDL particle number, Apolipoprotein B, PLAC testing and LDL particle size.
So how will this affect MY practice?
I think the guidelines are an opportunity to talk to people about their real diagnosis – their risk of cardiovascular disease.  As I have told many patients – to a certain extent, I don’t care what your cholesterol is, I care about you having a heart attack or stroke.  Cholesterol is a marker of how much artery clogging gunk is in your system.  There are several studies that show that the standard cholesterol profile underestimates cardiac risk.  I think that using the LDL particle number (LDL-p) is a better marker for assessing that risk.  If we reduce your LDL-p, your risk for cardiovascular disease goes down.  Statins are a tool (a very powerful one) to reduce cardiovascular disease risk.
I’m also not a fan of 10 year risk as a cutoff for starting treatment – I prefer lifetime risk, as the process that blocks your arteries is ongoing.  If we know 20 years before you have a heart attack that the risk is there, why wait until a heart attack is only 10 years away to start reducing risk?
How do I assess risk?
Risk can be estimated with a good history, a physical and testing.
History:
  • Prior heart attack, stroke or known cardiovascular disease?
  • Family history of heart attack or stroke – a male relative under age 55 or a female under age 65
  • Diabetes
  • High Blood Pressure
  • Smoking
Physical:
  • weight
  • waist size – belly weight is riskier than just being overweight
  • blood pressure
  • leg swelling
Diagnostic Testing
  • Cholesterol Assessment
    • there are several tests for this besides the standard cholesterol (called LDL-c) test which I will be reviewing in a future article in detail.  There have been several studies that show that other tests like LDL particle number (LDL-p) are better predictors of risk.
    • LDL cholesterol particle number (NMR Lipoprofile)
    • Apolipoprotein B (ApoB)
    • LP(a)
    • PLAC testing
    • Cholesterol particle size
  • C-reactive protein
  • Glucose
Once we put together your history, physical and test results we can have a discussion not about your LDL number, but your real diagnosis – your risk of cardiovascular disease.  The goal of that discussion is to reduce your risk of having a heart attack or stroke.
How can we reduce risk?
  • Blood pressure control
  • No smoking
  • Maintain a healthy body weight
  • Control diabetes
  • Being physically active
  • Control cholesterol
So the benefit of the new guidelines is they can inspire a conversation that leads to a proper diagnosis – not treating a number, but treating cardiovascular risk.

The path to Wellness begins with a proper Diagnosis

Exercise – The Power to Heal Yourself

 

exercise - the power to heal yourself
Visualizations are provided by www.theVisualMD.com

New Year’s is a time of resolution, renewal and rejuvenation.  People resolve to stop smoking, lose weight and exercise.  More gym memberships are sold in January than any other time of the year, and many go unused.  We all have this sense that we should exercise more – but have you ever wondered why that is such a universal sentiment?  What is it about exercise that makes it hard to maintain but remain so high on our wish lists?  What does exercise do for us?

Exercise impacts not only our muscles but almost every body function we have – it changes multiple hormone levels, insulin sensitivity, pain perception, hunger, sex drive and mood.  Exercise gives you the power to heal yourself.  Regular exercise promotes the following changes in the body:
  • increases the development of new blood vessels (can help in heart disease)
  • improves the functioning of multiple immune system aspects
  • decreases anxiety and depression
  • decreases inflammation
  • decreases pain in osteoarthritis
  • improves blood pressure
  • improves cholesterol
  • improves diabetes beyond weight loss
  • decreases the cravings for cigarettes
  • strengthens muscle fibers as well as promotes the development of more muscle tissue
  • improves digestion
  • stimulates the reward centers in the brain with substances called endorphins
  • and many other functions
These effects are separate from and in addition to the usual weight loss that accompanies exercise.

So what is exercise?

Exercise is any activity that maintains or improves physical fitness, health and wellness.  Studies have shown moderate activity will begin to show the benefits of exercise.  Moderate exercise is defined as 150 minutes per week (30 minutes/5 days per week) of brisk walking or similar activity.  The more intense your activity, the less total time you need – 75 minutes per week of intense activity will give similar benefits to the 150 minutes of moderate activity.
recent study in the journal Lancet  showed that in people with a high risk of heart disease and pre-diabetes decreased their risk of a heart attack by 10% just by increasing their walking by 2000 steps per day.   Another study in the British Medical Journal demonstrated that regular exercise was as effective as medication in preventing death from second heart attacks, rehabilitation from a stroke, improving heart failure and preventing diabetes.
The trick is maintaining the activity to continue reaping the benefits – if you don’t use it, you lose it.  Another way of looking at it is stated very well by Jim Rohn, an author and self development coach.  “Motivation is what gets you started, habit is what keeps you going.”

What do I recommend in my practice?

So, should everyone stop their medications if they exercise?  No, and certainly not without discussing your plans with your doctor.  Not every condition can be controlled with exercise, and not every medication can be safely stopped abruptly.  What I try to emphasize with my patients is that medication begins to correct a problem immediately – for example – lowering cardiovascular risk with a statin; adding an exercise program helps manage the long term risk.  We can then decide if immediate action is necessary, and set a goal – say losing a certain amount of weight.  When the goal is reached, stop the medication and reassess the condition.
By re-evaluating your diagnosis the effect of medication and the effect of your actions on your diagnosis can be measured, and your treatment plan revised.  You become an equal partner on your journey to wellness by revising your diagnosis!
Personally, I reconnected with running about 3 years ago. While there have been some ups and downs, I’ve managed to keep about 20 pounds off, and will be running my 7th half marathon next weekend. If you’d like to read about my own story on how I started maintaining a program, see this post – Exercise for a Cause, originally posted on TheVisualMD.com in 2011.

The path to wellness begins with a proper diagnosis

What is a Diagnosis? A rose by any other name?

You go to see a doctor with a painful shoulder. You tell the doctor that you can’t sleep because of the pain, and the doctor starts to make assumptions about your symptoms.  Before you get a chance to tell the doctor your story, you are told you slept on it wrong, and given a prescription for anti-inflammatory medication.  You don’t really improve and so you see another doctor for a second opinion.  A full history is taken, and you tell the doctor that you play softball on the weekends and you collided with the catcher while trying to score.  The doctor examines you and tells you that you likely have separated your shoulder.  An x-ray is ordered and it shows a shoulder separation.
Unfortunately, quick, easy answers and assumptions frequently lead to an incomplete diagnosis or a misdiagnosis.  These carry costs – your time and your money spent finding the correct answer, but more importantly, your health – which is why you go to the doctor in the first place.  Your story is like a puzzle, separated pieces that depict your diagnosis – the doctor has to put them together.
Your doctor needs to ask the right questions and listen to you to put your puzzle together.  It is what I am trained to do – make a diagnosis.  But what is a diagnosis?

  • A label
  • A code
  • A starting point for treatment

A diagnosis is a term with medical meaning.  It is comes from a physician’s synthesis of a patient’s symptoms, history, physical findings and laboratory findings.  A proper diagnosis is essential to begin a journey towards Wellness!

How does a doctor approach making a diagnosis?  We start by making a list – called a “differential diagnosis.”  As we take a history from a patient we start listing diagnoses that fit the symptoms.  As more of the story unfolds, the list is adjusted, the order is changed, items added and removed.  Then we examine the patient, and again revise the list based on our findings.

Tests are then ordered to do two things.

  • Definitely remove an item from list.
  • Confirm items on the list.

The approach to testing, however, doesn’t always focus on the most likely – there are other factors that determine the order of the tests.  If being wrong about a diagnosis has severe consequences, it may be tested for first even if less likely.

Finally, all the information gathered from the history, physical and diagnostic testing are put together and the list is put into a final order and a diagnosis is made.

If a treatment works, it confirms the diagnosis choice from the list.  If a treatment doesn’t work, the list needs to be re-examined and the history revisited to see what information was missing or not emphasized.  This is a crucial time in communicating with your doctor – they need to know what you are experiencing.  Based on that re-evaluation new tests may be ordered to further refine the list, and so on, until the final answer is revealed.

So what?  Why is this important?

First and foremost it determines treatment.  A diagnosis of Strep Throat requires treatment with antibiotics; a cold does not.
The diagnosis is what is used by insurance companies to approve tests and medications.
Diagnoses determine life insurance rates!

A diagnosis represents the last piece of the puzzle being put into place; it allows you and your doctor to chart a course of treatment and find direction after the confusion of not feeling well.

Without a proper diagnosis, you wander in the medical field, so remember:

The path to wellness begins with a proper diagnosis

 

Making a diagnosis – Who am I?

As you sit in the doctor’s office for the first time, your eyes note the array of diplomas and plaques on the wall. You have never met this doctor before, but your friend said they were good, or you picked them out of a book, or you were referred by another doctor, and you are about to share intimate details of your life with them. You have questions about how you feel, and you are going to get a diagnosis. But who is the person behind the plaques? What do all those fancy diplomas mean? After all, they call the person who finished last in the medical school class the same thing as the first – “Doctor”. Doesn’t it make sense that you know something about this person who is going to ask you personal questions and examine you? Shouldn’t you know more about this person you call “Doctor”? Well, I think the answer to this question is YES! So who am I? Keep reading…

All doctors are trained to make diagnoses, some within specialities – orthopedists, neurologists, surgeons, etc.  Most diagnoses are first evaluated by a primary care doctor.  There are several specialities that make up primary care doctors – who you see will depend on age, who practices where you live and possibly your gender.  Examples of primary care doctors:

  • Family Practitioner – a physician trained broadly to care for a person from birth to death
  • OB/GYN – a physician trained in women’s health and pregnancy care
  • Pediatrician – a physician who specializes in the care of children
  • Internist – a physician who specializes in the care of adults

How did I get here?

I am an Internist.  How did I come to call myself this?  Who am I behind other than the plaques on the wall? After graduating from college at Case Western Reserve University in Cleveland, OH, I attended the Albert Einstein College of Medicine, in the Bronx, NY, earning my MD with Distinction in Research.  I then spent 3 years as an intern and resident in Internal Medicine at New York University Langone Medical Center and Bellevue Hospital in New York City, completing the training to be a licensed physician.  I then served for an additional year as a Chief Resident for my program helping train the recent medical school graduates.  It was during this year that I took and passed an exam to become Board Certified in Internal Medicine by the American Board of Internal Medicine (ABIM).

 

I joined a prominent medical practice in NYC remaining on faculty at NYU School of Medicine.  During that time I refined my diagnostic skills, continued to train medical students and residents and eventually earned the rank of Assistant Professor of Medicine at the NYU School of Medicine.  After my first 10 years in practice as a Internist, I was tested again by the ABIM as part of a recertification process and again passing a comprehensive exam to remain Board Certified.

 

In 2012, after 13 years with my practice in NYC, my family and I decided to relocate to Phoenix, AZ where I joined Scottsdale Healthcare to bring my skills to a practice in the Arcadia area of Phoenix.  During my first year in Arizona, the American College of Physicians (ACP), which is the national society for Internal Medicine, elected me to Fellowship after a review of my professional work.  Doctors who have the initials FACP after their names have earned this distinction.

 

What is next?

This has been my path so far as an Internist.  I hope I have given you an appreciation of what the journey is like.  Along my journey I have worked with tens of thousands of patients to take the lead in helping them identify risks to their current and future health and well-being; prevent problems, and find the diagnoses that threaten their health today. It is with the realization that a proper diagnosis sets the foundation for all future health issues that I begin The DiagnosisMD blog.  My goal is to explain why a diagnosis matters, shed some light on the process a doctor uses to make a diagnosis, and explore interesting and timely topics in medical news.

So what is an Internist?  The ACP defines it as:

“Internal Medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment and compassionate care of adults across the spectrum from health to complex illness.”

Or as one of my patients from NYC used to say, “You are a Doctor’s doctor.”

 

I hope you enjoyed this look into my journey as a physican so far, and look forward to sharing my thoughts and reading your comments along this journey.

 

The path to wellness begins with a proper diagnosis