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A Guide to Heart Health

Statins, diuretics, calcium channel blockers. Are these the wonder drugs of the 21st century or simply the easy out when it comes to high cholesterol and elevated blood pressure? Find out what the experts think.

By Norine Dworkin-McDaniel

One in every three adults in this country is walking around with high cholesterol and a similar number of us have elevated blood pressure. Yet hearing a doctor say, "your LDL is up" or "you have hypertension" isn't likely to spark the panic that "you have cancer" does. Maybe it should.

"People don't just suddenly have a heart attack one day. It's a progression of uncontrolled high blood pressure and untreated high cholesterol that can lead to devastating consequences," says Lisa Price Stevens, M.D., an internist at Virginia Commonwealth University in Richmond and author of What's That? A Tale of Cholesterol (Trafford Publishing).

Fortunately, much can be done to get both conditions under control, starting with adding some exercise to your daily routine and tweaking your diet. When that's not enough, doctors agree that medication may be necessary to get you the rest of the way. Here's what you need to know to deal with these treatable warning signs.

If You Have High Cholesterol...

"Exercising regularly and reducing your intake of unhealthy foods may be enough to get mildly elevated cholesterol back into the healthy range," says Jerome Granato, M.D., medical director of the coronary care unit at Allegheny General Hospital in Pittsburgh and author of Living with Coronary Heart Disease (Johns Hopkins University Press). Cutting back on saturated fat, found in animal products, may lower cholesterol by about 10%. But some people have high cholesterol simply because their liver cranks out a ton of it. They could strip every last milligram of cholesterol from their diets and their levels still would be elevated because their livers produce so much, explains Dr. Granato. When you need to rack up some big-time reductions, doctors start scribbling prescriptions for medications like the ones following.

Common Cholesterol Medications

Statins: Considered the go-to drugs for cholesterol management, statins work their magic by limiting the amount of cholesterol the liver produces. These drugs—Lipitor (atorvastatin), Zocor (simvastatin), Mevacor (lovastatin), and Crestor (rosuvastatin)—block the enzyme needed to make new cholesterol while the liver absorbs and disposes of the LDL (bad) cholesterol already present in the bloodstream. All told, statins can reduce total and LDL cholesterol levels by 20% to 60% and lower the risk for heart attack and stroke by about 30%. But as powerful as they are—statins also help lower triglycerides and modestly raise HDL (good) cholesterol—they have no impact on the cholesterol we ingest, which is why having a prescription in hand is not a visit-the-drive-thru-free card. "Without prudent dieting, taking a statin is like bailing out a sinking rowboat without plugging the hole," says Dr. Granato.

New research suggests statins may protect people whose cholesterol levels are normal but have high levels of C-reactive protein, or CRP, a sign of artery inflammation (which can trigger heart attacks and stroke). If your LDL level is borderline high and you have some other risk factors, your doctor may want to do a blood test to check your CRP to determine if you should start taking a statin. Otherwise, the negatives associated with statins probably outweigh any benefits of taking the drug for someone with normal cholesterol.

Drawbacks: Statins can get your cholesterol into a healthy range but you'll need to keep taking them forever to stay there. Plus, you're committed to yearly or twice-yearly blood tests to ensure the statins don't damage your liver or break down muscle cells, a condition called rhabdomyolysis. (Minor muscle soreness affects about 5% of people taking statins, but in rare instances the destruction of muscle tissue leads to fatal kidney failure.)

In addition, statins don't mix well with grapefruit, grapefruit juice, or certain drugs, like many antibiotics and the blood-thinner warfarin. Finally, alcohol intake must be watched, since it too is eliminated through the liver.

Cholesterol Absorption Blocker: When you can't take statins, either because you have liver damage or can't tolerate the side effects, or if you're already on a statin but need to nudge your cholesterol down further, your doctor may prescribe Zetia (ezetimibe), a cholesterol absorption blocker. It stops the cholesterol you ingest from being absorbed through your intestines. Used with a statin, this may knock your LDL down another 15% to 25%.

Drawbacks: Ezetimibe lowers cholesterol, but it's not clear it prevents heart attack or stroke. "Unlike statins, it doesn't seem to protect against life-threatening events," says Dr. Granato.

Niacin: This B vitamin is one of the few drugs that effectively raise HDL cholesterol. It primarily prevents the liver from removing good HDL from the bloodstream, so levels stay high. Used alone, niacin can raise HDL between 15% and 35%; when paired with a statin, HDL may increase 50%. It's also helpful for lowering LDL and triglycerides.

Drawbacks: Taking over-the-counter niacin at high doses (1,000 milligrams or more daily) can cause some unpleasant side effects, like flushing, nausea, dizziness, and stomach upset. Niaspan (extended-release niacin), available by prescription, may reduce some of these symptoms. It still needs to be used judiciously and under supervision of a doctor who can monitor your liver function. High doses can cause liver toxicity, increase blood sugar levels in diabetics and, when paired with statins, raise the risk for the muscle destruction that can lead to kidney failure. A better way to raise HDL is by exercising and quitting smoking, says Pamela Douglas, M.D., cardiologist and professor of medicine at Duke University Medical Center in Durham, North Carolina.

Fibrates: When people have diabetes, which can automatically double, even quadruple, the risk for heart attack or stroke, fibrates are often partnered with statins to provide some extra protection. Fibrates are used to reduce cholesterol and triglyceride levels in the blood. The most commonly prescribed include Lopid (gemfibrozil) and TriCor (fenofibrate). In particular, fibrates help boost HDL, which tends to be lower in diabetics, by raising it about 10% to 20%. And they have the opposite effect on triglycerides, which are often higher in those with diabetes, by lowering them 20% to 30%.

Drawbacks: Stomach upset and an increased risk for gallstones are common with fibrates. Pairing fibrates with statins can also increase the risk for rhabdomyolysis.

Cholesterol Levels by the Numbers

Optimal
Total cholesterol: Below 200 mg/dl

LDL cholesterol:
Below 130 mg/dl if you're healthy
Below 100 mg/dl if you have heart disease
Below 70 mg/dl if you have several risk factors

HDL cholesterol: Above 60 mg/dl

Triglycerides: Below 150 mg/dl

Borderline High
Total cholesterol: 200-239 mg/dl
LDL cholesterol: 130-159 mg/dl
Triglycerides: 150-199 mg/dl

High
Total cholesterol: Above 240 mg/dl
LDL cholesterol: 160-189 mg/dl
Triglycerides: 200 mg/dl

If You Have Hypertension...

Two blood pressure readings over 120/80 mmHg, two weeks apart—to make sure it's not just nerves—will get you a diagnosis of prehypertension, says Suzanne Steinbaum, DO, director of the division of women and heart disease at Lenox Hill Hospital in New York. High blood pressure is the leading cause of stroke—untreated, the risk is raised two to six times. But even prehypertension (what used to be called "high normal") can quadruple a woman's risk of developing heart disease. Most of the individual hypertension medications out there lower blood pressure about 10% to 15%. But because the majority of people need to drop theirs further to get out of the danger zone, it's not unusual to be taking two or more. Each med works on blood vessels in different ways. Will you be taking these drugs forever? Doctors say that largely depends on you. For instance, following the DASH diet (an eating plan rich in fruits and vegetables, and low- or nonfat dairy; dashdiet.org) and being exceptionally strict about your salt intake (no more than a teaspoon daily) lowers blood pressure as effectively as any single hypertension medication.

Common Hypertension Medications

Thiazide diuretics: The first-choice medication for garden-variety hypertension (with some caveats), thiazide diuretics lower blood pressure by flushing the body of excess sodium and water and by dilating blood vessels. "Your body can only tolerate a certain ratio of sodium to water," explains Sarah M. Speck, M.D., medical director of the Swedish Heart and Vascular Institute's Center for Cardiovascular Wellness in Seattle. "The processed foods Americans eat are high in sodium, which cause us to retain water. That excess fluid pushes against your blood vessels, makes them less flexible, and drives your blood pressure up."

Drawbacks: Expect frequent trips to the bathroom. These drugs can also cause stomach upset, rashes, muscle cramps, lightheadedness, and sun sensitivity. Diuretics don't mix well with certain antidepressants, and may not be recommended if you have diabetes or lupus.

Angiotensin-Converting Enzyme (ACEs) Inhibitors/Angiotensin Receptor Blockers (ARBs): Very popular first-line treatments, these sister medications are the "push me/pull you" drugs for hypertension. They both target a substance called angiotensin II, which causes blood vessels to constrict. ACE inhibitors reduce the amount of angiotensin II made in blood vessels; ARBs block the effects of angiotensin II already in arteries so they can't constrict.

Drawbacks: ACEs and ARBs don't work as well as other medications for African-Americans for reasons that aren't completely understood. You should limit the amount of NSAIDs (ibuprofen, naprosyn) that you take for things like headaches or menstrual cramps when on an ACE or ARB, because mixing these drugs can damage the kidneys.

Calcium Channel Blockers (CCBs): Arteries are lined with smooth muscle and calcium channels that make these muscles constrict. Calcium Channel Blockers get their name from the fact that they block these channels so arteries relax and dilate. Unlike ACEs and ARBs, these medications are effective for African-Americans. It's unclear if these are beneficial for people over 65 whose arteries are getting stiff with age. CCBs are routinely used with diuretics and ACEs/ARBs.

Drawbacks: The problem is that when CCBs relax the smooth muscles in the arteries, they do the same thing to muscles elsewhere in the body—like the bladder and intestines, which can mean constipation and urinary problems. CCBs also relax the tiny capillaries, which can cause swelling in the lower legs.

Beta blockers: As other medications have come along, beta blockers, which reduce adrenaline and stop arteries from constricting, have fallen out of favor. "They're not as effective as other medications in terms of getting blood pressure down," says Dr. Steinbaum. And recent research suggests they carry a higher risk for stroke and overall cardiovascular-related deaths compared to other blood pressure medications. That said, these drugs still have a role in treating high blood pressure when a patient has other heart problems as well. "Beta blockers have a great track record for controlling heart rhythm disturbances and they're often used for people who've had a heart attack in order to prevent another," says Dr. Speck.

Drawbacks: When people complain about side effects of hypertension medications, they're usually complaining about beta blockers. Decreased libido and (for men) erection problems are common. So is fatigue. "When you knock down people's levels of adrenaline they can feel lethargic," says Dr. Speck.

Hypertension Levels by the Numbers

Optimal: 115/75 mmHg (if you're over 40)

Normal: Below 120/80 mmHg

Prehypertension: 120/80 mmHg - 139/89 mmHg

High: Above 140/90 mmHg

Cut Costs, Not Your Meds

Everyone's trying to do more with less these days, but the last thing to skimp on is cholesterol or blood pressure medication. Instead, try these cost-saving strategies from Michael Ozner, M.D., medical director of wellness and prevention at Baptist Health South Florida in Miami and author of The Great American Heart Hoax (BenBella Books).

A Word About Supplements

Two to Try

Fish oil: The American Heart Association recommends the omega-3 fatty acids for preventing heart disease. They decrease risk of arrhythmias and lower LDL, triglycerides, and blood pressure. They also raise HDL. If you don't have heart disease, you can get all the omega-3s you need in two weekly servings of salmon, herring, or other oily fish. If you have heart disease or need to dramatically lower your triglycerides, you'll need more, so talk with your doctor about taking a high-quality supplement.

Plant sterols/stanols: These compounds limit the amount of cholesterol absorbed from food, lowering LDL cholesterol by about 10%. The American Heart Association recommends them for people whose LDL cholesterol is over 160 mg/dl. You can buy plant sterol/stanol supplements over the counter or online. But they're actually a lot easier to take in fortified foods like orange juice, margarine, yogurt, and salad dressing.

Two to Skip

Vitamin E: A decade ago, cardiologists routinely recommended vitamin E to prevent cardiovascular disease, and there was good reason to believe it was helpful: Studies suggested that people who consumed high levels of vitamin E (through diet or supplements) had lower rates of cardiovascular disease. But in several large trials, when researchers gave vitamin E supplements to healthy people and to those with established heart disease or diabetes, it did not prevent heart disease, heart attack, or stroke. And in fact, in one trial, vitamin E even raised the risk of heart failure.

Red Yeast Rice Extract: It's not that red yeast rice isn't effective for lowering cholesterol—it is. A recent study found that Chinese heart patients who took red yeast rice extract for more than four years reduced by 45% their risk of having a repeat heart attack and dying. The problem is the red yeast rice extract sold in the U.S. does not contain any of the protective natural statins typically found in red yeast rice. The compound is considered a regulated (and patented) drug and therefore cannot be sold over the counter in the U.S.

More Heart Health Facts

Originally published in the February 2009 issue of Family Circle magazine.

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