The Senior Center for Health & Security

Seniors and Heart Disease: Lower Cholesterol, Cut Your Risk

Introduction

Cardiovascular Disease is the number one cause of death among Americans. While the true cost in human suffering and lives lost is incalculable, we do know that heart disease costs our healthcare system hundreds of millions of dollars every year. The good news is that heart disease is preventable. Advances in the development of life-saving medicines and treatments have enabled millions of Americans to manage their heart disease and improve their quality of life - but only if they take them.

High cholesterol is one of the leading causes of heart disease, and also one of the most treatable. More than 90 million Americans are estimated to have elevated blood cholesterol levels. While anyone can suffer from high cholesterol, according to the Centers for Disease Control (CDC), seniors are at an unusually high risk. Poor diets, sedentary lifestyles, and a lower compliance rate for taking prescribed medication are all to blame.

What is Cholesterol?

Cholesterol is a soft waxy substance found among the lipids, or fats, in our bloodstream. People get cholesterol in two ways, our body produces it in our liver and we get it from the food we eat. Foods from animals, including eggs, meat, poultry, fish, and dairy products are the main dietary sources of cholesterol. A well-balanced diet containing high amounts of food from plants - fruits, vegetables, grains, nuts, and seeds - along with regular exercise is one of the easiest ways to control cholesterol levels. But for many, diet and exercise alone is not enough.

How Does Cholesterol Cause Heart Disease?

Excess cholesterol builds up in the walls of your arteries. This leads to "hardening" of the arteries, a condition where arteries become narrowed and blood flow to the heart is slowed down. If blood supply to the heart is completely cut off, the result is a heart attack.

There are no symptoms of high cholesterol. It is important for all Americans, especially those over 65 to get regular blood tests to check their levels of cholesterol. According to the National Cholesterol Education Program, as men and women age, cholesterol levels rise.

With passage of the Medicare Modernization Act of 2003, seniors on Medicare became eligible for routine cholesterol screenings from their doctor. Prior to implementation of this law in 2005, only those diagnosed with heart disease could get cholesterol screening under Medicare. Seniors can now get free cholesterol screenings every five years, and those newly enrolled in Medicare can get a free "Welcome to Medicare" physical that examines all the risks for heart disease.

Reducing the Risk of Heart Disease

According to the American Heart Association, American's over the age of 65 are at the highest risk of developing heart disease. At this age, initial heart attacks tend to be more fatal than those suffered at a younger age.

The first step to protecting yourself from heart disease is maintaining a healthy lifestyle. This can include a balanced diet, weight loss, exercise, smoking cessation, and limiting the amount of alcohol consumed. The American Heart Association recommends a diet of lean meats, poultry, and fish combined with low-fat dairy products, whole grains, fruits and vegetables, combined with a minimum of 30 minutes a day of vigorous exercise. Their lifestyle modification program encourages seniors to:

• Use up at least as many calories as you take in.
• Eat a variety of nutritious foods from all the food groups.
• Eat less of the nutrient-poor foods.
• Don't smoke tobacco - and stay away from tobacco smoke.
• If you drink alcohol, drink in moderation

Often, lifestyle modification with diet and exercise is not enough. In that case, your doctor may prescribe cholesterol-lowering medications, called statins.

Cholesterol Medications

Statins are a class of prescription drugs that lower the level of cholesterol in the blood by reducing the production of cholesterol by the liver. Combined with diet and exercise, statins are estimated to lower blood cholesterol levels by as much as 40 to 60 percent. The National Cholesterol Education Program estimates that as many as 9 million Americans are currently taking prescription drugs to lower their cholesterol - far fewer than could benefit from them.

There are currently 6 statins on the market:

• rosuvastatin (Crestor)
• atorvastatin (Lipitor)
• fluvastatin (Lescol)
• lovastatin (Mevacor)
• pravastatin (Pravachol)
• simvastatin (Zocor)

While each medication is different, as a class, statins have proven to be quite effective in lowering cholesterol and reducing the overall risk of heart disease in older Americans. Each medication works a little differently in each individual, so it is important to have a wide variety and number of medicines for doctors to prescribe.

Statins Save Lives - If we Use Them

A study published by the medical journal Circulation in 1998 found that statins dramatically reduced the risk of dying from heart disease. Their researchers found that for every 10 percentage points cholesterol was reduced, the risk of dying from heart disease dropped 15 percent. One 2005 study, the first to examine statin use in a large national sample based on their level of heart disease risk, reported that only half of the people at moderate or high risk for heart disease are getting the recommended cholesterol-lowering drugs that can reduce their risk, and save their lives.

Stunning research over the past two years indicates senior citizens were the least likely to take coronary artery medications - medications that could save them from a heart attack or death. Older patients, those with heart failure, smokers, and diabetics were least likely to consistently take medication, according to one study reported in Circulation: Journal of the American Heart Association. In another, massive survey released April 19, 2005, four in 10 seniors said that they hadn't taken all the drugs their doctors prescribed for them in the past year -- either because the costs were too high, because they didn't think the drugs were helping them, or because they didn't think they needed them. Another survey of seniors in August of 2002 found nearly one quarter of seniors reported skipping doses of medicine or not filling prescriptions because of costs. Seniors (and near seniors), their families, and caregivers must work to understand and reverse this deadly trend.

Cost Savings

The CDC estimates that nearly 930,000 Americans die from heart disease annually - that's one death every 33 seconds. In 2005, the cost of heart disease and stroke in the United States is projected to exceed $394 billion -- $242 billion for health care expenditures and $152 billion for lost productivity from death and disability. The economic impact of cardiovascular diseases on our nation's health care system continues to grow as the population ages. The CDC estimates that the cost of heart disease and stroke in the United States is projected to be $431.8 billion in 2007, including health care expenditures and lost productivity from death and disability.

Wider use of cholesterol-lowering statins can ease these costs down the road. A January 2001 study published by the American Academy of Family Physicians, found that:

• Cost-benefit analyses show that lipid-lowering therapy is relatively cost-effective, compared with other interventions. In middle-aged patients with CHD (secondary prevention), the estimated cost per year of life saved as a result of statin therapy is between $4,500 and $14,000.
• The cost for primary prevention of CHD with a statin in middle-aged patients is about $20,000 to $40,000 per year of life saved. These figures compare with a cost of $40,000 per year of life saved for hemodialysis and $70,000 per year of life saved for coronary artery bypass surgery for one-vessel coronary disease.

A May 12, 2005 HealthDay Reporter article reports that British researchers with the Heart Production Study reported their research in the May 12, 2005 issue of The Lancet and found that "the cost of avoiding future medical problems justifies the wider use of statins," and a 22% reduction in hospitalization costs for the group that took the statins.

Other Benefits of Statins

Statins have not only been clinically-proven to lower cholesterol and reduce the risk of heart disease, they have been linked to lowering the risk of dying from emphysema, chronic bronchitis, influenza, and pneumonia. Canadian researchers have also reported that statins act against sepsis, a dangerous blood infection.

A recent study tracking 27,000 women over 11 years found that controlling cholesterol may be even more important for women than previously thought. The study, published in the journal Neurology, found that healthy women with no history of heart disease or stroke significantly increase their chances of having a stroke if they have high cholesterol.

The study, conducted by researchers at Brigham and Women's Hospital in Boston, a Teaching Affiliate of Harvard University (and supported by the National Heart, Lung, and Blood Institute and the National Cancer Institute, among others), focused on women who were healthcare professionals who were at least 45 years of age, had no history of cardiovascular disease, cancer, or other major illness. The women's cholesterol levels were checked just once, at the beginning of the study.

The results of the study indicated some 282 strokes occurred during the 11-year period, meaning nine out of every 10,000 women had a stroke each year. The study found a strong correlation between total cholesterol levels and the later incidence of stroke. The findings show otherwise healthy women with high cholesterol at the beginning of the study were more than twice as likely to suffer a stroke compared to healthy women with lower cholesterol levels.

Personalized Medicine and Statins

A November 2006 report, "The Case for Personalized Medicine" explained why personalized medicine is necessary for select optimal therapy.

"Physicians have long recognized that patients can respond very differently to the same medication. For example, a statin drug used to lower cholesterol levels may work for only 30 to 70 percent of patients (Spear et al. 2001). Studies have linked differences in drug responses to differences in genes that code for the production of drug-metabolizing enzymes, drug transporters, or drug targets (Mangravite et al. 2006; Rieder et al. 2005; Terra et al. 2005). Detection of these genetic differences provides the opportunity to use genetic or other forms of molecular screening to select optimal therapy the first time and avoid a trial-and-error approach to prescribing."

That personalized approach is critical. While statins can have side effects (and some may be dangerous), the appropriate statin in the appropriate dose can be safe and effective in lowering cholesterol. Here are two expert observations from the American Heart Association website: "As a class, statins are very safe medications. They have been widely used for almost 20 years and several studies clearly show that statins reduce heart disease, stroke and total mortality," said senior author Richard H. Karas, M.D., Ph.D., director of the Preventive Cardiology Center and the Women's Heart Center at Tufts-New England Medical Center in Boston.

"The absolute risk with this statin is low. The overwhelming majority of people who are taking it will have no problem at all," said Alice K. Jacobs, M.D., president of the American Heart Association. "This analysis shows that statins are safe, and that physicians should continue to offer their patients what is still one of the best tools we have for treating elevated cholesterol." Karas urged doctors to individualize treatment, reserving the strongest statins for patients whose cholesterol levels resist standard treatment. Most people with moderately elevated cholesterol levels respond to the time-tested drugs. "The risks of specific statins should be weighed for each patient," Jacobs said. "In general, physicians initially should prescribe the lowest dose of statin to bring a patient's cholesterol to target levels."

This advice, based on post-marketing analyses, emphasizes the need for a good, solid doctor-patient relationship, where the discussion begins with proper diet and exercise, and if necessary, continues on to the choice of the right statin in the right dose for the best results. There are several different statins, and one "size" clearly does not fit all.

Conclusions

As we, an aging nation, stand at the edge of a retirement population numbering more than 70 million people, one of the biggest threats to every one of those older Americans is heart disease and stroke. Cholesterol is a risk factor for both. For those who've changed their diet and exercised to no avail, they may be able to their lower cholesterol through statins. Patients, physicians, and all health care providers must determine the most effect treatment to lower cholesterol, not only for the good of most, if not all, aging Americans, but for the economic well-being of the nation as a whole. Physicians must work tirelessly to (after appropriate, frequent, and continuous testing) support lifestyle changes and, if necessary, prescribe the most effective statin for the individual patient. And finally, every patient taking a prescription cholesterol-lowering medication must religiously follow the prescribed treatment regimen. Millions of precious lives and hundreds of millions of dollars will be saved as a result.

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