Take holistic view of heart attack risk

Dear Dr Roach: I am a 66-year-old male, 6 feet, 3 inches tall and weighing 220 pounds. I am active and fit. My cholesterol recently has been between 208 and 214 in the past two physicals. My HDL is 54. My doc said it is time for 20 mg Lipitor, as better eating did not lower it as I had hoped. Since I started, my cholesterol is 145.

My girlfriend is also 66, 5 feet 6 inches tall and 135 pounds. She is active with me. She has been taking red yeast rice for years to help with her elevated cholesterol, two pills daily.

During a recent blood test, her cholesterol was around 245-250. Her HDL is 93. Her primary care doctor says not to do anything different, but I’m thinking she should also be taking Lipitor or an equivalent.

Aren’t both men and women’s cholesterol levels recommended to be below 200? Should she stay on red yeast rice or talk to her doc again about a Lipitortype medication?

P.B.

Answer: The goal for treating cholesterol is not to make the numbers better; it’s to reduce the risk of a heart attack. Consequently, it’s important to take a holistic view of a person’s risk of having a heart attack before thinking about using a medication. This includes a careful evaluation of diet, stress and exercise. Family history is an often-neglected risk factor, and there are nontraditional risk factors (one is the quality of personal relationships) that most physicians don’t spend enough time obtaining, let alone discussing how to improve.

Most calculators are unable to synthesize all of these risk factors. The most commonly used ones look at blood pressure, cholesterol, age and sex: putting your information (prior to starting Lipitor) into one of these calculators gives the result that your risk of a heart attack or stroke in the next 10 years is 12.3 percent (I made the assumption that your blood pressure is about average).

With this result, most guidelines agree with your doctor that moderate or even high-dose Lipitor is a good choice for you.

Your girlfriend has the advantage of female sex and a high HDL. This protects her to a large extent, so her 10-year risk is only 5 percent (with the same assumptions about her blood pressure).

The guidelines agree with her doctor that no Lipitor or similar medicine is indicated.

The guidelines recommend statin drugs in people who are over 7.5 percent (they vary a bit), but there is nothing magic about that number. Some people will want to be protected even at lower risk, while others who really don’t want medication will prefer not to take it. There are many ways to reduce heart disease risk without using medicines for nearly everybody.

I should note that guidelines are not commandments. There are times when, through other risk factors or her personal preferences, treatment might be appropriate for her.

Finally, red yeast rice contains a substance which is identical to the active ingredient in lovastatin, one of the first statin drugs. The amount of the substance (monacolin K) is variable batch to batch, generally smaller than in the prescribed drug, and there are not long-term trials showing reduction in heart attacks, as there are with statin drugs, in people at moderate to high risk.