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Friday, April 8, 2011

Getting to Know Your Heart Risks

The View from the Office



 Does a Healthy Lifestyle Mean That You Never Have to Take Pills?

       If you have a healthy lifestyle, does that mean you shouldn't have to take pills?  Of course, I believe that everyone should have a healthy lifestyle. And increasingly more and more of us are achieving this goal. I've noticed that one of the things that happen to people who have healthy lifestyles is that they think they shouldn't have to take pills. The belief is this: If I keep working on my healthy lifestyle that should bring my blood pressure down, lower my cholesterol, and prevent me from ever getting diabetes. This principle is sound and applies most of the time, but there are many, many exceptions. The logic is especially true if you've had a healthy lifestyle all your life since childhood. But even then there is the matter of your genes. A healthy lifestyle does not change your DNA. The purpose of this week's article is to show you a way to know if taking some extra pills for your blood pressure, cholesterol, or general vascular disease prevention (like aspirin) is a good idea. 
     The problem that I am addressing is the fact that so often in my office I am trying to urge patients to start taking a blood pressure medicine so that their blood pressure doesn't linger around 148/94 mm Hg, but actually gets down to 120/80, where your heart and blood vessels will function optimally. Similarly, when it comes to cholesterol, I have no problem convincing the patient whose total cholesterol is over 300 mg/dL that they should take a medication called a "statin", but when I try to convince a patient whose blood pressure is just a little high, like 148/94 mm Hg, or whose "bad" cholesterol (LDL) is only 10-20 points above normal, which is 100 mg/dL, that they would really benefit (i.e., add years to their life) if they got that cholesterol way down into the good range like around 70 mg/dL, they just don't want to do it. They don't want to add a new medication, possibly for life, for just a minor abnormality. The problem, however, is that even a minor abnormality over a long, long period of time does significant harm. When you add several minor abnormalities together over a long time, they do a great deal of harm. This is the whole rationale of analyzing cardiac disease risk over multiple risk factors. Treatment is not just for those with severe abnormalities; it is for anyone who wants to enjoy the benefit of health for a much longer period of time.
     Think of it this way: Would you have ask your auto mechanic to do just "half" of a tune-up? Would you want to put used motor oil into your engine? Remember that your body has pipes and pumps that need engine cleaning agents regularly titrated to your biological parameters (e.g., blood pressure, lipid levels, glucose, etc.). Just think of your blood pressure medications, cholesterol lowering medications, aspirin, etc., as engine-cleaning detergent gasoline. 
      Of course, not all medications will make a big difference. How do you know which ones will give you the biggest bang for the buck. Until recently this has been a very difficult calculation to do and the scientific evidence has been hard to interpret. But now we have some wonderful tools from the American Diabetes Association that gives you a simple graphical visual illustration of just how much benefit you will get from lowering your blood pressure just 5 points, or 10 points, or 20 points. You can do a similar calculation for your weight and dramatically see how much difference losing 5 lbs, 10 lbs, or 20 lbs will make for you. In this article I am going to demonstrate how the ADA's program, "My Health Advisor" (My Health Advisor (http://www.diabetes.org/diabetes-basics/prevention/my-health-advisor/  or search for "my health advisor" in Google), can help you pick exactly what medication, or what level of blood pressure or cholesterol will do you the most good.

     To start with you have to enter some basic data about your self. Here is a summary of the data the program collects.

   Then based on this profile, the program (which takes some 10-15 minutes to run your numbers through the extensive Archimedes database) produces a report to show you the your probability of a heart attack, stroke, diabetes, etc., if you just keep tooling along just as you are. One of the nice things about the program is that it lets you save a copy of your data and your report so you can revisit it in the future and play out a variety of "what if" scenarios based on where your biological parameters are and where you would like them to be.





      You see in the graphic above that there are slider bars next to your weight, cholesterol, and blood pressure, and there are check-mark boxes for other interventions such as stopping smoking, taking a baby aspirin daily, or taking a prophylactic heart medication like an ACE-inhibitor or a beta-blocker.




    In the graph above the pink bars shows the reduction in my risks if I just get my blood pressure down to 120/80 mm Hg.

     In this graph you see the effect if I go all out and lower my weight from 210 to 185, if I lower my LDL cholesterol from 94 to 70, and lower my blood pressure from 130/80 to 120/80 mg Hg, and start taking a heart-protective medication (an ACE-inhibitor). The combination of interventions would lead to a very impressive reduction in overall risk. 
     Major reductions in risk like this are a very good thing, and the way to get there is by taking a medication. Thus my advice is to try to move away from the hostility towards taking medications. Stop telling yourself that it is all a plot just to make money for the drug companies, or that it will cause you lots of problems from side-effects. What these medications give you, if you lower your cardiac risk, is extra years of life--very high quality life, in fact, if you have a healthy lifestyle. When you evaluate the trade-off--a good number of extra years of life against a few annoying side-effects, the balance of benefits to risk is very positive. On the other hand, if you chose not to avail yourself of the wonderful benefits of these medications, that too has a side effect--dying early is a rather nasty one.
      We are blessed to live in an era in which we have truly effective medications, now all blissfully available as low-cost generics. Unfortunately, we have come to take for granted this embarrassment of riches. We forget that 30 years ago the medications to achieve these goals were not available or were so expensive that they were out of reach of many. I think we are all well aware of many, many people who died back then from diseases that are now easily treatable. That simply doesn't need to happen any more. 


     To maximize your life opportunity you should build your health on two firm pillars:  (1) you should create and sustain a healthy lifestyle for you and your children based on the formula for health (0-5-10-30-150); and (2) You should use the "My Health Advisor" program to really understand your risks and to make your own decisions about blood pressure, cholesterol, and heart-protective medications. These are all very inexpensive and very effective. No corporation needs profit from your decision if you use a generic, and the generics are every bit as good as the fancy brand names (which are all destined to become generics anyway). If you really value health, you will get aggressive about asking for these medications because they can do for your health such an amazing thing--keep you on this earth so you can be with your friends and family a good bit longer. All your friends and family would want you to.

COMMENT: In my separate publication in April, FP Revolution (FP Revoluation recent issues) I will describe in detail how to use the other ADA program for risk assessment in diabetic patients (Diabetes PHD, http://www.diabetes.org/living-with-diabetes/complications/diabetes-phd/   Diabetes PHD or enter the search term "diabetes phd" into Google). This program allows diabetic patients to change their risk not only for heart attacks and strokes, but also for kidney failure, blindness, and foot amputation. All of this represents high-tech medicine at its best. And best of all--you are in control all the way!

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