New Cholesterol Recommendations After A Stroke

Feb 25, 2020

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

"Toc Tic" Those were the only two words on an Oil of Olay ad. But they were perfect. They catch your eye. You wonder why "Tic Toc" is reversed. Then you realize the implication they the moisturizing cream Oil of Olay reverses aging. Perfect. I love the podcast and CBC radio show Under the Influence by adman Terry O'Reilly. O'Reilly always tells such unexpected and entertaining stories from the world of advertising. He was talking about how "Toc Tic" was his favorite Oil of Olay print ad and how this unusual ad communicated so much with just two words. The other day, I thought I must have stumbled into a real life Under the Influence story. I was pulling out of McDonalds, and the billboard to my left read, "Come in & see The Worst Customer Service Ever. One woman said on Trip Advisor!"

Many food ads claim their product is cholesterol free. Cholesterol isn't necessarily a bad thing. Cholesterol is a naturally occurring substance in your body. It is essential for life. If you had no cholesterol in you, you would die. Cholesterol helps form bile acids in your digestive system, hormones in your endocrine system and important components of every cell membrane in your body. The trick is though, your liver can make all the cholesterol your body needs. And eating food that has a lot of cholesterol in it doesn't necessarily make your cholesterol levels go up. The cholesterol in the food you eat doesn't go directly into your blood stream. Your liver makes cholesterol out of foods with a lot of saturated fats in them.

Why does your doctor test your blood for cholesterol if it is essential for life? Your doctor cares about blood cholesterol levels because if they are too high for too long you have higher chance of getting a heart attack or a stroke. Every 7 minutes in Canada, someone dies of cardiovascular disease. That is why we care about blood cholesterol levels. And that is why cholesterol medications are so common.

Statins are the most popular cholesterol medications. HMG-CoA reductase inhibitors, or statins are very good LDL lowering medications. The magic number we usually aim for is an LDL of 2.5 mmol/L or lower. If we reduce someone's LDL to 2.5 mmol/L or lower, we help reduce hardening of the arteries or atherosclerosis. Statins have been shown to reduce death due to heart attacks and stroke. In fact, if we reduce someone's LDL with statins, we can reduce their chances of heart attacks and strokes by 25% to 35% with five years' use. As effective as statins are, like every other medication, they do have potential side effects. The statins may upset your stomach. Less common, but more serious problems can include liver issues. Your doctor will check your liver function with a blood test. Other signs of liver problems include flu like symptoms, yellow eyes or skin, dark urine and belly pain. If you start getting a lot of muscle pain, please contact your doctor. Severe muscle injury from statins is rare, but can damage the kidneys.

The statins do a good job of reducing LDL. But, what does all this LDL, and HDL stuff mean? Your liver makes cholesterol, and it puts it into the blood stream. Cholesterol is a kind of fat or lipid. Since blood is mostly water, cholesterol doesn't mix well with it. The liver has to mix the cholesterol with proteins to get it to stay in the blood. This mixture of cholesterol and protein is called a lipoprotein. If you take a blood sample and spin it really fast in a centrifuge, it separates based on density. Different layers in the sample have different densities. Low Density Lipoprotein or LDL is often called "bad" cholesterol because it transports cholesterol from the liver to places like the lining inside the arteries. Through a complicated series of events, these cholesterol deposits can cause blockages that slow or stop blood flow. If blood flow to the heart muscle is stopped, that is a heart attack. If blood flow to the brain is stopped that is a stroke. High Density Lipoprotein or HDL is called "good" cholesterol because it transports cholesterol away from the cells lining the blood vessels. This can decrease the chance of blockages.

Some newer information now says we should be more aggressive in stroke patients. There is evidence that after a stroke or transient ischemic attack (TIA), that cholesterol goals should be even lower. TIA is another name for mini-stroke that happens then goes away. Remember we usually aim for an LDL of 2.5 mmol/L. But data suggests getting to an LDL of 1.8 mmol/L or lower prevents a recurrent cardiovascular event in about 1 in 42 ischemic stroke or TIA patients treated for 3.5 years. To get the LDL to under 1.8 mmol/L often you will have to add another medication like ezetimibe to a patient's statin. Usually we'll check someone's LDL 4 to 12 weeks after starting a statin and then once a year after that.

Statin drugs like atorvastatin and rosuvastatin sometimes get some bad press about their risks. Let's try to put the risks in perspective. If 20 patients with heart disease take a statin for 5 years, we will prevent one heart attack or stroke. That's pretty good. Muscle pain from statins is rare and the really bad muscle damage called rhabdomyolysis happens in less than one in 43,000 patients. There are alternatives to statins, but they don't have the decades of good research behind them. Ezetimibe and the PCSK9 inhibitors do lower LDL, but none of them has been shown to reduce the chance of a heart attack or stroke when used alone. And the PCSK9 inhibitors cost over $7000 per year. Finally, don't pick fish oil supplements or red yeast rice instead of statins. There is some evidence that fish oil and red yeast rice might be healthy things to add to your diet. But neither has been shown to reduce the risk of heart attack or stroke.

The "Worst Customer Service Ever" billboard was for Prairie Supply Co. I've been there, as I'm sure many of you have. Dale and his staff pride themselves on great customer service. The first thing the billboard did right was to catch my attention. I can't remember the last time I took a picture of a billboard with my phone. The second was it told a great story that I wanted to know the ending of. Who was this disgruntled customer? What happened to her? Then I started rooting for Prairie Supply Co. Why was she treating them so unfairly? Then, most importantly, I wanted to go to Prairie Supply Co and tell them I thought they were being treated unfairly. All of that in 5 seconds or so. The power of advertising always amazes me. In a world of internet trolls and viral memes with one Billboard, suddenly "Toc Tic" and my view of a complaint about store's brand is reversed.

As always if you have any questions or concerns about these or other products, ask your pharmacist.

The information in this article is intended as a helpful guide only. It is not intended to be used as a substitute for professional advice. If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

Heart Research Institute - http://www.hricanada.org/about-heart-disease/facts-about-heart-disease

Why So Many of Us Die from Heart Disease - The Atlantic - https://www.theatlantic.com/health/archive/2018/03/heart-disease/554951

Stroke Best Practices - https://www.strokebestpractices.ca/recommendations/secondary-prevention-of-stroke/lipid-management

 


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