Category Archives: cholesterol

An Update on New Research – Straight from the Source!

IMG_8348rt5x7bwThere is always plenty of research being conducted on heart disease prevention, but this week I decided to go straight to the source. This week I will be blogging directly from the Cardiometabolic Health Congress in Boston – a collection of presentations on recent concepts and new research in the treatment of conditions like high blood pressure, high cholesterol and diabetes. The goal? To prevent heart disease and stroke.

Here are some highlights from the first day:

High Cholesterol: The big news in cholesterol treatment is the development of a new class of potent drugs, PCS-K9 inhibitors, (Which I previously reported on here) which are different from statins – they lower cholesterol potently, but must be given by injection. For now, they are reserved for patients with seriously elevated levels while taking statins – or those intolerant of statins.

While statins are very effective in patients with a history of heart disease, many patients who take them have never had cardiovascular disease – they were prescribed purely for prevention. Many people given statins are actually at low long term risk – and the statin may not impact their risk further. Recent research shows that we can refine which patients benefit by using a test to look for early evidence of plaque buildup in the arteries. This test, called a coronary calcium scan (or heart scan) is cheap and quick, and can clarify which patients really will benefit from a statin.  Here is a recent article from the New York TImes with more details.

Obesity: Anyone who has tried to lose weight know the frustration of seeing the weight return over time. We often attribute this to poor will power, but research now shows that certain hormones are activated that actually “stimulate” the body to gain weight – like a weight “thermostat” that tries to return to a prior setting. New research is trying to interrupt this cycle and allow weight to stay off.

Research also shows that there are different “types” of obesity – many people consider themselves overweight, but are otherwise very healthy – normal blood pressure, blood sugars, and cholesterol. In others, their weight leads to chronic issues and eventual complications. So always think of your weight in the context of your overall health.

Finally, when we decide to eat something, we assume we are doing so in response to feeling “hungry”. But research show that we often eat in response to other cues – sights and smells, emotional states, and availability of food. (A great example of “mindless” eating is chomping on popcorn while we are engrossed with a movie) So if you struggle with willpower, try to limit these non-hunger “cues” – remove unhealthy food from the house, and try to steer clear of temptations as you go about your day.

Tomorrow, we will hear about new research into high blood pressure and diabetes. (As always – these are general concepts – only your doctor can address your specific health issues).

A New Option for Patients Who Can’t Tolerate Statins

IMG_8348rt5x7bwFor over 20 years, statins (such as atorvastatin and simvastatin) have been one of our primary weapons to fight heart and vascular disease, because of their ability to reduce cholesterol, and subsequently prevent heart attacks and strokes. But in many patients, statins are poorly tolerated or ineffective at reducing cholesterol to  the desired target.

Recently, a new class of cholesterol-fighting drugs were discovered, and the first of these agents has been approved by the FDA. These medications, called PCS-K9 inhibitors, work differently than statins, and do not seem to have the common side effects of statins, such as muscle soreness. They appear to markedly lower cholesterol, and appear to be safe.  This article in the Wall Street Journal nicely summarizes the promise of these drugs, as well as the drawbacks (the drugs are very expensive, and must be given by injection).

In addition to those drawbacks, the new agents have yet to establish a long-term track record of safety and prevention of heart attacks and strokes. So initially, these agents will be reserved for patients who have genetic elevations of cholesterol, and those with known cardiovascular disease for whom statins are ineffective or not tolerated. In the near future, more agents will become available (lowering their price), and further studies will guide how to best use them.

In the meantime, statins remain our best weapon against high cholesterol – and are safe and well tolerated, even when given for many years. And as the above article documents, well-done studies have shown that most muscle soreness in patients on statins is either unrelated to the medication, or resolves when a different statin is used.

And of course, remember that diet and exercise, not just medications,  are effective weapons against high cholesterol.

More articles about cholesterol:

Overview of Prevention

The New Cholesterol Guidelines: What do they mean for you?


Asian Americans Face Greater Risk for Stroke and Hypertension

Asian Americans are at higher risk for stroke and hypertension compared to whites, according to a study examining U.S. death records from 2003–2010.

IMG_8348rt5x7bwAlthough heart disease is the No. 1 killer of all Americans, certain races and ethnic groups face higher cardiovascular risk than others. Asian Americans are the fastest growing racial/ethnic group in the United States, yet little is known about heart risks in distinct subgroups of the Asian American population.

Published in the Journal of the American College of Cardiology, a recent study analyzed death records for the six largest Asian-American subgroups: Asian Indian, Chinese, Filipino, Japanese, Korean and Vietnamese. Together, these subgroups make up 84% of the Asians in the United States.

After comparing U.S. death rates from 2003–2010, researchers found that stroke and high blood pressure was more common among every Asian American subgroup compared to non-Hispanic whites. Compared to whites, Asian Indians and Filipino men also had greater mortality from coronary artery disease—a condition that occurs when the heart’s arteries narrow, often due to the plaque build-up on the arterial walls. (text taken from

Until further studies clarify the specific reasons for elevated risk in Asian Americans, the goals for prevention in this population are similar to all adults, with a few areas of emphasis:

1. Blood Pressure Control – monitoring blood pressure – .and prompt treatment of elevated readings – it is important for all adults, but in Asian American’s we may need to emphasize more thorough monitoring, and consider intervention ( either lifestyle changes or medications) at an earlier age or with lower blood pressure targets. Here is more information.

2. Manage Your Cholesterol – in recent years we have certainly learned more about specific changes of cholesterol in the Asian population. For example, here is an article I co-authored which looked at specific cholesterol findings in Indian Americans.  Even though the spectrum of specific cholesterol abnormalities vary among the various agents are groups, the lifestyle advice to minimize the impact is universal: Reduce intake of saturated fats, processed grains, and minimize wheat based carbohydrates. Here is more information.

3. Stop smoking and minimize tobacco exposure. Hopefully the impact here is self-explanatory. Here is additional information.

4. Monitor Blood Sugar – Type 2 (or “adult onset”) diabetes is far more common in certain Asian populations (such as Indians), especially those that have moved to Western countries that eat highly processed diets. In many Asians, diabetes can develop even in the absence of the usual weight gain (e.g. abdominal fat) typical in other populations. Ask your physician about screening recommendations for those at risk of diabetes.

4. Stay Active! Regular readers of our blog should be well versed in the many benefits of the ultimate medical therapy: Regular exercise. Here is an overview of the benefits of exercise, and here is even more information.

For now, the screening recommendations for prevention of heart disease and stroke in Asian Americans are no different from the population at large. However, there is some evidence that certain screening tools may benefit certain populations. These include advanced blood testing and imaging to screen for early coronary plaque. If you are concerned about your risk, you should ask your physician whether additional screening may be useful. or even consider calculating your very own “Heart Age”.  In the meantime, clinical studies are providing more and more information about cardiovascular risk in this growing segment of Americans.

The New Cholesterol Guidelines: What do they mean for you?

Kanny S Grewal MD 5x7 (4)As you may of heard, some experts created new guidelines for clinicians to treat high cholesterol, and they have generated quite a bit of controversy, since they are a big departure from prior guidelines. The big new difference is that they no longer emphasize having “target” levels of cholesterol, LDL, etc and rather focus on just using statins at low, moderate, or high doses based on the patients level of “risk”, which is calculated from a formula based on age, sex, and various risk factors. This could be a sound approach, since some experts feel that simply being on a statin will reduce heart risk, regardless of how much a patients “numbers” actually change. They also conclude that most other types of cholesterol medications, besides statins, don’t have much impact on heart disease and are not generally recommended. The controversy is that the recommended formula to calculate an individual’s long-tern risk has not been thoroughly tested, and it seems to overestimate risk in many groups of patients.

What messages can we “take home” from these new guidelines? Here are a few:

1. The best treatment for high cholesterol remains lifestyle – diet and exercise.

2. The decision to start medication therapy should be individualized and come from the patient, after a thorough discussion with their clinician about risk.

3. Patients with established heart disease clearly benefit from statin therapy, which clearly reduces future risk of heart attack and stroke.

4. For patients without a history of heart disease or stroke,the benefit may be very negligible, unless they fall in a “high risk” group based on other risk factors such as diabetes. These patients should discuss the pros and cons of medication therapy with their doctor.

4. One way to think of statin therapy: it reduces future risk of heart attack and stroke by one-third in everyone. That means a 300 lbs diabetic who just had a heart attack, and a 30 year old fitness fanatic in perfect shape. The difference is the baseline risk. If you start with a risk of 1 in 100 of a heart attack the next 5 years, is that 1/3 reduction really worth taking a potentially toxic pill every day? Probably not. But 1 in 10, or 1 in 5? Probably yes.

So if you have been recommended therapy, or already on therapy, for high cholesterol, ask your doctor about your cardiovascular risk both with and without medication. And more importantly, stay active, maintain your weight, and focus on your diet!

Here is an some excellent summaries of the debate about the new cholesterol guidelines:

Dr. Krumholtz discussion in New York Times

Experts Reshape Treatment Guide for Cholesterol