Narrator:
0:01
Welcome to MedEvidence, where we help you navigate the truth behind medical research with unbiased evidence, proven facts powered by ENCORE Research Group and hosted by cardiologist and top medical researcher, Dr. Michael Koren.
Dr. Michael Koren:
2:25
I'm actually really excited to be here today because Miciah and I are colleagues in the same practice. I'm a noninvasive preventive cardiologist. Dr. Jones is an interventional cardiologist. He's the quote "plumber" that fixes things. So we each bring our own perspective to the treatment of coronary artery disease and cardiac problems. But Miciah is remarkably versed in diet, exercise and prevention. So he and I have done other educational sessions and it's fabulous learning from you. So I appreciate you being part of this and sharing your insights with our audience.
Dr. Miciah Jones:
3:03
Yeah, absolutely. Thank you for having me. It's always a pleasure to be able to use the background and exercise physiology I got from undergrad. It's not often times you go into medicine and you continue to be able to use all the education you got about exercise, diet and nutrition. So just bringing that to the table for an interventional cardiologist, I think, is a unique perspective. Working with someone like Dr. Koren to help facilitate that is excellent.
Dr. Michael Koren:
3:26
Yeah, it's a tremendous perspective and it's refreshing also. So thank you for that. So we're excited to hear what you have and what we do for these sessions. I know some of you have been here before and we present some general information about lipids, cholesterol and cardiovascular prevention, and then we like to open it up so that you can ask your individual questions, and that usually is the most lively part of our session. So hopefully we'll have some good questions saved up. If you think of something, please write it down and we'll try to address everything that we possibly can address. So that will be at the end of our formal comments. So, to start off, I wanted to congratulate Sharon for this concept of mocktails and medicine. I thought that was a neat and creative way to engage people and get people to come out on an evening, to get them to share their evening with us, and I have to admit, sharon, that this is pretty good. I'm really enjoying it. Now I also know that Sharon has a little bit of a mischievous streak, and so it's not pasture to spike the punch, if you will. So if I start slurring my speech during this presentation, you know why. So let's get to the first slide. So we'd like to get the audience involved. So do you know this typical patient? A middle-aged person comes to the emergency room with chest pain and receives the diagnosis of acute coronary syndrome. So which treatment is appropriate? Is it high-dose statin medication immediately? Is it usual starting dose of statin medication? Is it cath stem procedure, if needed, then stem, or wait four weeks to heal after the procedure and then treat with cholesterol meds if needed? So let's get a sense for the audience. Who thinks the answer is number one? A few people. Who thinks the answer is number two? A couple who thinks the answer is number three it seems like most people are saying that and who thinks the answer is number four? Okay, nobody for that. So, Miciah, what is the?
Dr. Miciah Jones:
5:41
answer yeah. So the answer is actually number one. You start the high-dose statin medication. You know immediately.
Dr. Michael Koren:
5:49
Yeah. So that surprised a lot of people Is that people think of medicines as something that you kind of start at your leisure. But we actually know with an acute coronary syndrome that you need to hit people hard immediately with statins and that's quite effective. You actually see results from that within a couple of months of the event and it's life-saving. So we like to use this question to get people to understand that at times, treating the cholesterol is actually something of urgency. So there's really no long-term downside to this. This is basically a free benefit by just being aggressive.
Dr. Miciah Jones:
6:25
Yeah, absolutely. The statins have multiple benefits, not just lowering the cholesterol, but there is an acute phase of the heart attack. You know, some anti-inflammatory effect to the statin, which is one of the reasons we may think that it works so well immediately and why we recommend that you actually use that even before you do the procedural therapy, which is quite interesting. You know you think you need to do the procedural therapy, but the medicines certainly play a complementary role in this and are very important up from Absolutely, absolutely.
Dr. Michael Koren:
6:53
So one of the things that we have to be careful about when we do our educational events is to make sure that people don't get lost in the jargon. And we have a lot of jargon in our hands. Yeah, we do, so we want to share with it, and there's actually a lot of overlap in the terms we use. So we're going to define some of these terms so that, if we use them, you have a better sense of what we're talking about. So, for example, we also often talk about something called an acute coronary syndrome or ACS, and that's a general term for all situations involving reduced blood supply to the heart muscle. Then we have the famous term called a STEMI, which is what my first phone call when I hear about a STEMI is to call Dr. Jones. And so once you tell us, tell us what STEMI is.
Dr. Miciah Jones:
7:36
Yeah, so absolutely. A STEMI is a particular type of heart attack where you have certain changes on what's called your electrocardiogram or EKG and that results in a heart attack by complete blockage in the coronary artery. So it is an acronym, okay, we use that for short to talk for short amongst ourselves. This is part of the medical jargon, but it is a heart attack that is usually caused by complete blockage in a coronary artery and is it implication in terms of treatment?
Dr. Michael Koren:
8:04
if you wanna share that with me, yeah, and absolutely.
Dr. Miciah Jones:
8:07
This is one of the ones where you have to be in there and treat it immediately. This is why we talk about all those signs and symptoms of a heart attack and we do the job educating people what that is that sub-sternal chest pressure, radiation to the jaw, arm, back with the understanding that not everybody may have the same symptoms. Women in particular may have pretty atypical symptoms, fatigue, shortness of breath, things like that. So we do the education so people know. But this is a very time-sensitive issue and we have a very limited time, Dr. Koren, to get to these patients to help them out.
Dr. Michael Koren:
8:41
Yeah, we like to get this procedure done either a stent or some sort of intervention within 90 minutes of presentation of symptoms. So if you have this sign on your EKG and we do what's called a STEMI alert, everybody's gonna be running around like their hair is on f ire and trying to get to the cath lab and get that vessel open.
Dr. Miciah Jones:
8:59
Just like a pit crew, a NASCAR event everybody's gonna be going doing things simultaneously, same time, getting in there making sure that everything's getting done to help that person immediately, right?
Dr. Michael Koren:
9:11
and we have an NSTEMI.
Dr. Miciah Jones:
9:13
Yeah, so the NSTEMI is slightly different from the STEMI in that it's based on there's no definitive EKG changes called ST elevation. So this may actually be from a complete or a partial blockage in the artery. Sometimes these do present as complete blockages, but most of the time it's due to a partial blockage in the artery.
Dr. Michael Koren:
9:34
And if it's complete, it's sometimes a smaller vessel. That's not quite as critical. So how about myocardial infarction?
Dr. Miciah Jones:
9:42
Yeah, so myocardial infarction is just a term that we use to signify there's been damage or death of an area of the heart muscle, and that's usually the medical term for a heart attack. So any of these things we mentioned above may cause a myocardial infarction or death or damage to the heart muscle.
Dr. Michael Koren:
9:59
Coronary thrombosis.
Dr. Miciah Jones:
10:01
So this involves a clot inside of the artery that supplies blood to the heart.
Dr. Michael Koren:
10:07
And finally coronary occlusion.
Dr. Miciah Jones:
10:10
So an occlusion is a structure of a coronary artery that can cause a heart attack. Interestingly, occlusions can be caused by many things. So occlusions can actually sometimes be caused by a very thick heart muscle squeezing down on the artery, obstructing flow. Occlusions can be caused by plaque buildup. Occlusions can be caused by clot or thrombus that builds up in the artery also, so there's multiple mechanisms for occlusion of an artery.
Dr. Michael Koren:
10:39
Thank you. So you can see that there are a lot of overlaps in the terminology. So hopefully, when we use these terms, you'll have a better understanding. The other thing we like to ask the audience because there's been a misconception about the difference between heart disease problems in men and women, so let's address that. So we like to do this as audience participation what is the leading cause of death in females in the United States? Cancer, heart disease. Look at that. We have people that know the answer before they even saw the choices. I'm impressed.
Dr. Miciah Jones:
11:10
Yeah, very well.
Dr. Michael Koren:
11:11
Alzheimer's disease, nagging husbands or talking heads in the media? And you guys were right on it it's heart disease. So I'm actually very impressed that people knew that before they even showed the choices. Okay, so let's move to men. What is the leading cause of death in males? Nagging wives, nagging wives, nagging wives or heart disease?
Dr. Miciah Jones:
11:42
It's interesting because it's usually those first three things that usually get them to the hospital.
Dr. Michael Koren:
11:48
All right, so, okay so, but it's true that men and women present differently, so I don't know if you want to jump into this point, yeah absolutely.
Dr. Miciah Jones:
11:58
The presentations are different. Right, we can't treat women like they're a little bit smaller men. That's not how it works, okay, the women's present very differently with their symptoms. They tend to present with more vague symptoms, not your classic what you read about crushing chest pain, where somebody comes in clutching their chest right. That just doesn't happen, for whatever reason. When women do have the heart attacks, they seem to experience more complications associated with that heart attack, not only from the heart attack itself, but also procedural complications for management of that heart attack, which is interesting.
Dr. Michael Koren:
12:35
So men die suddenly. You've heard the term sudden cardiac death, where basically you just dropped dead and that's more likely to be the primary presentation for a man compared to a woman. But once women get into the system they have fewer , but when they're treated for the they have higher complications. And you actually can see that over here where on the right side, you can see that overall, after the diagnosis of a heart attack women actually have a higher mortality than men over the next year. So that's the bad news. The good news is that those death rates have actually come down quite a bit over the last 20 years. So this is kind of the big picture. I like to show this slide because it gives you a sense for what progress we're making with treating heart disease in the United States and what needs to be done in the future. So this is a graph that's publicly available that looks at the total number of cardiovascular deaths in the United States since 1900. And you can see, starting at 1900, it was relatively low and that's because people died of other things, typically infectious disease and other things. But over the course of the next 50 years the risk of cardiovascular death went up tremendously and by the 1950s it was far and away the number one cause of death in the United States. And then, starting around the 1960, we started to get a handle on the problem and it stopped going up. And then actually, lo and behold, between the 1980s and about 2015, we actually saw a reduction in the number of cardiovascular deaths, and that's due to a number of things. It's due to having ICUs, it's due to better stents, better coronary interventions, better drugs, particularly statins. The introduction of statins in the late 1980s, early 1990s, had a profound effect in reducing heart disease deaths in the United States, as you can see from this slide. But around 2015, that trend started reversing and we're now seeing an uptrend. Now, keep in mind, the population in the United States is also going up. So this is not a rate, this is total number of deaths. So the rate has come down even more than the total number of deaths, but that also is upticking in the last five to seven years. And if you have any speculation on that, why, after about 20 to 30 years of progress, we're seeing a plateau? Any thoughts?
Dr. Miciah Jones:
14:55
Yeah, there's a couple of thoughts there. One, we may not be getting out there to get in front of this. Two obviously we had a big pandemic, and one of my concerns during the pandemic was interestingly is we actually saw a drop of about 25 to 30% in the rate of those STEMI heart attacks that we talked about earlier. Right, well, these people didn't just stop having heart attacks, a lot of them just stopped getting medical care, exactly.
Dr. Michael Koren:
15:24
Yeah, so there's a lot of factors. Obviously, with the obesity epidemic, there's more risk factors to treat and I actually have a theory is that when statins became generic and I actually had a conversation about this with one of the audience members before the session we had fewer reminders from the drug companies about how good these drugs are. So we used to have representatives from the drug companies come into our office all the time and remind us to use Lipitor and Crestor and all these drugs, and, of course, they were self-serving, they were selling it and they were making their living based on selling the drug. We don't deny that. But they're also helping people, yeah, so interestingly, that phenomenon is not the way it was 20 years ago, where we have a lot more interaction with sales people, and I think that also has some impact.
Dr. Miciah Jones:
16:12
Yeah, I think anytime you have newer medications or entering the market, newer technologies enter the market, you certainly need to partner with the industries to make sure that those things are being touted out there for their benefits and people are being educated about the appropriate use. And you bring up an interesting point about that, as part of the industry's job was to educate people about their use, exactly.
Dr. Michael Koren:
16:35
And you can see, highlighted in the red box is the number of COVID deaths in 2020, which was the biggest year for COVID deaths in the United States. You can see that COVID deaths, even at its worst, was only half of cardiovascular deaths and, to your point, cardiovascular deaths went up between 2019 and 2020, probably because and even though, people weren't coming to the hospital. So people are still dying, to your point. That's right, so very excellent point. Okay. So the good news is that cardiovascular death rates are down 50% over the past 30 years due to better treatment and diet, but no great progress in the last five to eight years. So we gotta get back on it. There's a death every 33 seconds and it's one fifth of all US deaths 60,000 US deaths per month from heart disease Pretty amazing. Yeah, this is projected to rise 46% by 2030, up to eight million annual deaths, and about one in five heart attacks are silent.
Dr. Miciah Jones:
17:34
And that's the scary part silent. So 20% of these heart attacks that occur there's no warning sign.
Dr. Michael Koren:
17:42
Person has no symptoms, right, they don't have no idea what it is, yeah, and for some people they just need to be screened. So if you have risk factors and you are somebody that's concerned, get to a physician that can help you, and we have tremendous ways of diagnosing early coronary disease that we didn't have 10, 20 years ago.
Dr. Miciah Jones:
18:04
Yeah, absolutely right. Advances in imaging technology right. Risk calculators right. This is one of the big things that we advocate for is knowing your risk. What is your risk for having an event? If you don't ever find out what your risk is, it's very difficult to modify that risk and have an effect, isn't it?
Dr. Michael Koren:
18:21
It is, and this is a slide that shows the risk calculator from the American College of Cardiology. So just walk people through some of the things that contribute to that.
Dr. Miciah Jones:
18:29
Yeah, so what we have in a risk calculator is we have things that we can change, different variables that we can put in based on what somebody comes to us with right their age, their ethnicity, their gender. We can put in their blood pressure. Are they on medication for their blood pressure? Are they a smoker? Did they recently quit? How recently did they quit? We can put in all these factors and we can actually get an estimate of their risk over the next 10 years of having a heart attack or stroke, but also their lifetime risk of having an event. Which is huge. About informing discussion with patients about their management options Absolutely.
Dr. Michael Koren:
19:07
And, at the end of the day, decisions about medications is all about risks versus benefits, and the benefits only come when we know that you're at high risk for the disease. So it starts with calculating your cardiovascular risk. Okay, so let's jump into cholesterol. Obviously, that's a major interest of ours. I've spent a lot of my professional career studying this and helping develop products for it. So let's define it for people. Let's help people understand that, so go ahead.
Dr. Miciah Jones:
19:38
So cholesterol, you need cholesterol. Cholesterol is a basic building block for every cell, particularly that cell wall that keeps all those nice little things inside that cell. You need the cholesterol to maintain the integrity of that. So cholesterol is essential for all tissues.
Dr. Michael Koren:
19:55
Yeah, one point, a little trivia question I like to remind people, is that Every cell in the body can make its own cholesterol from just basic nutrients, except one, which are the eyelashes. For some strange reasons the eyelashes lost that ability. But every other cell can actually make its own cholesterol, so you don't have to ingest cholesterol for your body to make it.
Dr. Miciah Jones:
20:17
Yeah and absolutely. And these cholesterol derivatives that your body uses. They use it for everything from the integrity of the cell wall to hormones that your body makes A lot of. Those are based in cholesterol and without those your body does not function normally.
Dr. Michael Koren:
20:36
So the tricky part is that we need cholesterol for all these bodily functions. Cholesterol is a fatty substance. It doesn't dissolve in blood, which is a liquid substance. So how do we get it around if you have a fat that needs to get to different parts of the body through a liquid?
Dr. Miciah Jones:
20:52
Yeah, so you make it soluble somehow, and your body does that, and it turns it into these different particles that we'll talk about what those particles are.
Dr. Michael Koren:
21:03
And name for it is lipoprotein. That's right yeah that's right. So when you talk about bad cholesterol and LDL which we'll get to in a second these are lipoproteins, which is a mixture of fats and proteins. So this is what they look like.
Dr. Miciah Jones:
21:16
Yeah, so these are the different common types of lipoproteins. You have your LDL, you have your HDL, you have your VLDL triglyceride and then you have something called Lp(a). So, taking these, starting from the LDL, this is the big bad wolf. Right, that's the bad cholesterol, the big bad wolf. This is the one that you want to try to lower. It transports fats and this is the one that, if there's too much there, can cause significant problems. This is the cholesterol that promotes vascular inflammation, causes heart attacks, strokes, plaque buildup, calcium in the arteries right, and that can occur in any arterial system in your body the arteries of the legs, your aorta, the arteries of your brain, the arteries of your heart. So lowering this LDL cholesterol can reduce your risk of heart attacks and strokes. So that has been one of the most important things we've done in modern medicine to figure out a way to treat this.
Dr. Michael Koren:
22:08
Yeah, and I think virtually every cardiologist would agree that it's probably the primary preventive cardiology measure is lowering the cholesterol, and every study shows that if you lower LDL, however you do, it is good for your heart. Even back in the day, we actually did allele bypasses. We did bypass surgery on the gut to lower cholesterol and that worked. And the latest thing is OZMPIC, which helps you reduce weight and lowers your LDL. That also prevents heart attacks and strokes. So whatever you do to lower LDL is a good thing.
Dr. Miciah Jones:
22:41
I love doing these with Dr. Koren because he gives me all this medical history that I have no idea about. It's great.
Dr. Michael Koren:
22:48
Yeah, that was called the POSCH study, published in 1990. And they actually took people with familial hypercholesterolemia and did allele bypasses before we had any drugs and they actually live longer because they had less cholesterol problems. Amazing, all right. So now HDL, the good cholesterol.
Dr. Miciah Jones:
23:04
So HDL is your good cholesterol. This is the one that gets it away from the arteries, right? So if the LDL is the one that's carrying it around the arteries, floating through the arteries, the HDL is a good cholesterol pulling it out of that bloodstream and getting it taken care of and bringing it into the liver so it can be appropriately metabolized. So this is the one that is associated with a protective effect on your health. Helps maintain good flowing blood through those blood vessels, because you're not dealing with all this inflammation, yeah.
Dr. Michael Koren:
23:35
So the interesting thing about that is there's no doubt that the higher the LDL, the better off you are, but artificially raising HDL hasn't worked. It hasn't. That's absolutely right, it's been. One of the frustrations in medicine is that we have products that raise HDL but they don't improve outcomes, whereas lowering LDL, which is a poison, always improves outcomes.
Dr. Miciah Jones:
23:56
But interesting enough if you do the lifestyle things to bring up the HDL.
Dr. Michael Koren:
24:01
That works.
Dr. Miciah Jones:
24:02
That works right. So if you artificially increase it it doesn't work. But if you have a healthy diet and you exercise and you raise that up naturally, it seems to work wonderful.
Dr. Michael Koren:
24:10
Yeah, so the theory is about that and it has to do with the difference between measuring something that's a poison and then measuring something that's a transporter. So we think that the HDL story is about how efficiently the molecule transports cholesterol back to the liver, which is not specifically reflected in changes in HDL. So very, very interesting and that's why we do studies is to figure these things out. That's right, yep, so the VLDL and triglycerides?
Dr. Miciah Jones:
24:40
Yeah, so the VLDL and triglycerides, these are very low density. When we talk about the density, how packed together are these lipoproteins, these fats, how packed together are they? This is a very low density. So this is really your triglycerides, or something that had undergone minimal metabolism, right, that's transferring through the bloodstream there. Interestingly enough, this is a very good marker particularly triglycerides of how has your diet been recently, right, how has your diet been recently and this is one of those things that we can tell Important as an energy source, important as we've evolved as humans, because we need that if we don't have ready access to food. But nowadays for most of us, particularly in America, that's not as big of an issue. So then it becomes a problem. We went back to that slide in the 1900s we talked about, you know, people weren't dying of cardiovascular disease, they were dying of other things, right? The food supply wasn't as good as what it is now.
Dr. Michael Koren:
25:40
Exactly, yeah, and the two triggers for higher triglyceride levels would be carbohydrates, sugars, particularly an alcohol. So often if we have a patient that has high triglycerides, there's a lot of dietary advice and counseling that goes into their treatment. Okay, and how about the really really, really, really bad cholesterol?
Dr. Miciah Jones:
26:00
Yeah, so the really, really bad cholesterol is the lipoprotein little way. It's kind of the evil twin, so to speak, of the LDL. This is the one that is very, very inflammatory. Okay, and when we talk about the blood vessels, they do not like any kind of inflammation. The blood vessels will do what they have to do to protect themselves and part of that plaque buildup and calcium buildup that happens in the arteries, that's the arteries way of trying to protect itself from these kind of chemicals.
Dr. Michael Koren:
26:31
And we actually had a discussion with one of the audience members about lipoprotein little a and they mentioned they're going to see a cardiologist and not all cardiologists check for this and the reason they don't always check for it is because there's no specific treatment for it. But that is changing and here at our research centers in Northeast Florida we are using products that can lower lipoprotein little a by up to 90%.
Dr. Miciah Jones:
26:55
And I think that's interesting. You know, I'd like to get your thought on this. If you have a patient who you know has a very high risk due to lipoprotein little a, you screen for it, would you be more aggressive in managing some of their other risk factors?
Dr. Michael Koren:
27:11
I would but not everybody shares that opinion. Some people feel that why check something if you don't specifically treat it? But I agree with you is that you may not be able to treat that, but you'll treat everything else more aggressively because of the very high risk. The other thing about lipoprotein(a), or Lp(a), is that it's genetically mediated, so the gene for Lp(a) is transmitted from parents to kids and if you have the gene, then there's a 50-50 chance that your kids will get it. So typically Lp(a) runs in families, meaning that if you have a family history of premature heart attack or stroke, you should get your Lp(a) checked, in my opinion, because you're at particularly high risk.
Dr. Miciah Jones:
27:49
That's a good point. So not only by checking it are you helping out that one person. You're potentially helping out dozens of others in their family?
Dr. Michael Koren:
27:57
Absolutely, and we have lots of stories of family members that have this particular problem, and we've helped the younger members of the family by identifying the problem earlier. So again, 20% of the US population has this 1 in 5. And I'm most screened for you. One of the things that we get asked about is the cost of it. Fortunately, it's not an incredibly expensive test, but if you make an appointment with us, we'll do it for free because we have funding through the clinical trials that we run. All right, so let's get to the meat and potatoes, about how to avoid meat and potatoes. How do we limit heart disease, stroke and vascular complications? And we talked about the big picture, so we have what's called our non-modifiable risk factors.
Dr. Miciah Jones:
28:39
Yeah, so these are the things that you absolutely can't control. You can't control your family history, you can't control how old you are, you can't control your ethnicity, you certainly can't control the weather. So you can't control any of these things. Trying to do that doesn't work, so these are the things that you just bring with you to the table as a risk.
Dr. Michael Koren:
28:59
Of course, if you have multiple elements of those non-modifiable risk factors, you should probably be more aggressive at working on the modifiable risk factors Exactly.
Dr. Miciah Jones:
29:08
And that brings us to these modifiable risk factors. These are things that we can control and, like Dr. Koren said, if you have some of the non-modifiable ones, you want to be ultra aggressive about working on these other things you can control, like the lipids. If you have a high LDL and triglycerides, we know that's bad, right Diabetes and not having that appropriately treated. Lack of physical activity, smoking, high blood pressure, stress, believe it or not, huge, huge. Absolutely, and sometimes very hard to avoid, very hard to avoid actually can contribute to the high blood pressure, can contribute to the people feeling the need to smoke. I've actually had patients who I've said, listen, you needed a career change or you need to retire, and they've done that and their high blood pressure went away completely off of medications. So stress can be a very, very powerful risk factor that can be modified.
Dr. Michael Koren:
30:01
Yeah, and of course, physical activity is an area I know that you're particularly interested in, and that makes a difference also is just getting exercise into your schedule, so it's something you do regularly. It will help lower your blood pressure, bring down your weight and reduce your stress.
Dr. Miciah Jones:
30:15
I think that's a wonderful point. I think that one of the things we need to do as a medical community is do a better job of defining exercise, because if you ask a patient to exercise and you ask 10 patients, how many different answers do you get? Exactly, yeah.
Dr. Michael Koren:
30:28
Well, early on in my career, I kind of learned that my advice to patients wasn't that specific and I would say, ok, well, let's start your exercise program. Why don't you walk five miles a day for the next 10 days and see how you feel? And I got to call 10 days later. She says, doc, I'm 50 miles from home. Now what do I do? So you have to be pretty exact about your advice. Yeah, absolutely, you want to be specific about it, ok. So, getting back to drugs now, we talked about the fact that statins have had a big impact, but even with their impact, there's still something called residual risk, and that means, when you look at the progress we made, there's still more progress. So this is a nice slide from the National Institute of Health that shows that we made great progress between the year of 2020-10. In fact, we brought down cardiovascular disease by 26% and coronary heart disease by 34%, but there's still a lot of Americans that are suffering from these problems, and this is after statins were fully implemented amongst the US population.
Dr. Miciah Jones:
31:32
Yeah, absolutely. And then this just speaks to the need to continue to educate not only the general population but also physicians on what they can do to help educate their patients in a way that makes sense to the patients as well.
Dr. Michael Koren:
31:46
So the term we like to use in cardiology and in research is called the residual risk, which is the risk that's left even after your best interventions. And that's what we're working on in research as we speak is to continue to reduce the residual risk.
Dr. Miciah Jones:
32:02
And this is very exciting, particularly as somebody who is on the other end of this when that residual risk is still there and now the patient's coming in with their event. Well, what can be done to help prevent this event from ever occurring?
Dr. Michael Koren:
32:16
Exactly All right. So statins are wonderful drugs. I compare them to mother's milk, quite frankly. But there's a lot of stuff out there suggesting, maybe, that they're bad. So why don't you share your thoughts about that and why do you think that there's all this noise out there about statins?
Dr. Miciah Jones:
32:34
Yeah, I've heard a lot of things. Statins are bad for you. They don't do anything. All you're going to get is side effects, and they've been blamed from any number of issues I've seen. But the data just out there isn't show it. It takes very few people that we have to treat in order to save one life on a statin.
Dr. Michael Koren:
32:57
And these are the actual data. I know this gets a little technical, but you can see that on the slide here to your. It'd be on the right side is what's called a meta-analysis, and these are a lot of studies that we have been involved with here. In fact, there was a trial called the Alliance Trial, and I was the doctor in charge of that trial, and so I have a lot of firsthand personal experience with these things, and you can see that when those boxes, the white boxes, are to the left, to that line that runs down, that's good, and you can see that virtually every study of statins showed that it's good. There's really been no thing. There's not a single result on the wrong side of that line, and so you should have a very strong level of conviction that when you're taking a statin, you're going to do something good for yourself. The other way to look at it is on the other side, which would be to the right here, which shows you the more you lower your cholesterol with a statin, the better off you are, and you can see that line shows that if you lower your cholesterol very little or zero, you get zero benefit, but as you lower your cholesterol more and more. You get more and more reduction in heart disease, so this is undeniable. The data for this is beyond any type of criticism.
Dr. Miciah Jones:
34:14
And these are big, big numbers. When we talk about these trials, these aren't small trials. These trials are thousands of patients over a very long period of time.
Dr. Michael Koren:
34:24
Yeah, and this was published in Europe, so they use a term called millimoles, but that really means it's 38 milligrams per deciliter, 38 points on an American scale. So for every 38 points that you reduce your LDL cholesterol, you get a 21% improvement in your cardiovascular risk. So that's pretty impressive, very so. What about side effects? Well, the biggest side effect that people talk about is the muscle aches, and the beauty of doing clinical trials is that we do trials where we're blinded. We do double blind trials where you don't know what you're on, and that's really the only objective way to see if there's any difference. So in the pink or the red, you can see that when we do blinded studies where people are either on a statin or on a placebo, there's very little difference in muscle aches, not zero difference, but very little. So you can see myologies. That's a medical term for muscle aches and it's 83 versus 78. For any muscle pain, 164 versus 153. That's the rate per 1,000 people. And so you can see that there are slight differences and that's where the word get out that statins cause muscle problems, but that these are minimal differences.
Dr. Miciah Jones:
35:36
Yeah, absolutely, and it's interesting that there's even newer data out there to suggest that these muscle aches can actually improve with exercise.
Dr. Michael Koren:
35:45
Yeah, and this is the interesting thing is that that was only in the first year. So once you're on a statin for over a year, there's zero difference. So pretty impressive, and the bad reputation for statins and muscle aches is probably largely undeserved. However, we've all had patients that truly have intolerant statins. It happens. It's rare but it does happen. But fortunately we're doing things to try to address those issues, for patients.
Dr. Miciah Jones:
36:11
And it's nice, because the statins are also, like, you know, any other thing you may acquire a taste for in your life. When most people start drinking coffee, they might not drink it black. All right, they might drink it with a little bit of cream, a little bit of sugar, a little bit of Splenda. Over time, your taste may change. Same thing with the statins right, you may start on one statin. Okay, yeah, that wasn't the one for you. Right, let's move on to the next one. That wasn't the one for you. We find out you like your coffee black with one sugar. Okay, great, we figured out, we got you on the right statin medication now. So there will be a little times where you have to do a little trial to find out which one works for you. But that's not like most things in life.
Dr. Michael Koren:
36:50
Yes, and although we do a lot of work with other newer products, we always preach that everybody at high risk for heart disease or the history of heart disease should be on a statin Absolutely, and this slide gives you another way of looking at that. So the road of lipid lowering therapy started with statins, and a listing of all the statins is up there, or less call Mevacor, Provacol, Crestor, Zocor and Livalo are statins that are on the US market. All of them are generic now, except Livalo Livolo, and there are other agents that were developed that you can see a little bit down the road, as edomai, bicepia, bimpedoic acid, which is next-litel, and different fibrates, and then we also have what's called monoclonal antibodies in red. There are three of those on the market that you can see there. What we're working on as we speak is something called an antisense oligonucleotide or ASO. Pelacarsin is the name of it. We have small interfering RNA. A new drug in the market is called incliscerin or lecvo, which we did a lot of work on and that we were personally very involved with here in Jacksonville. Opacirin is another that we're working on. That I mentioned to you was a publication that came out recently, and down the road we're going to have vaccines for cholesterol and then ultimately edit the bad genes that are causing the problem. So there's been a tremendous amount of progress in this area, but it all starts with stentons. Absolutely, and this is actually the article that we published here in the journal called Nature Medicine, showing that we can reduce lipoprotein little a by 90% with a drug called opacirin, a research done here in our backyard. All right. So conclusions Although we recognize that every cell can make cholesterol intrinsically without needing circulating LDL, we also know that lower LDL is better. Clinical trials show that lowering LDL is a first priority and that cardiovascular benefits occurred very low levels of LDL without causing safety problems. Ie, you can get your LDL down to virtually nothing and not have to worry about it. And current studies that you can take part in here evaluate other lipid particles, and we have our team around that's more than happy to walk you through that. So if you have a concern about your cholesterol, grab one of our team members and we'll get you involved.
Dr. Miciah Jones:
39:52
Narrator:
40:49
Thanks for joining the MedEvidence Podcast. To learn more, head over to medevidence. com or subscribe to our podcast on your favorite podcast platform.
