Welcome to Dr. Warrick's podcast channel. Warrick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warrick believes educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love. Hi, my name's Dr Warrick Bishop and I'd like to welcome you to my consulting room. Today I'm going to take the opportunity to record a consultation with a patient and today's patient is Michael. Michael has agreed to have this consultation recorded. Could I just confirm you're happy with that Michael? Absolutely. And Michael has given me some forewarning that today he's apprehensive about taking his statin therapy. So I thought this was a good opportunity. to engage in a conversation that's really important. By way of background, Michael is a 72-year-old gentleman who's been fit and active his whole life. He's slim, he looks after himself, and really came in with a several-week history of worsening shortness of breath and chest pain on exertion. We did a stress test, as appropriate, reproduced his symptoms at a low workload, demonstrating that he most likely had tight blockages of his arteries. put him immediately on medication, and the next available opportunity undertook invasive coronary angiography, which confirmed the suspicion that he had a tight blockage, in this case in the LAD, and a large diag artery. And within a couple of days, we've been able to make arrangements for percutaneous intervention with stent placement in the LAD. The diagonal branch hasn't been stented, but looks good. He's on all the appropriate therapy, dual antiplatelets, plus a cholesterol lowering agent, and he's coming today wanting to talk about his medication. With that as a background, Michael, can I invite you to share with me what you want to talk about today? Okay. I feel, coming from the amateur's point of view, I feel almost reluctant to put my case... Because I'm sure you've heard it a million times before and you're a little bit bored about the explanation. Like many people, I've done a little bit of research on YouTube, on the internet. And even before that, a year ago I was invited by the Menzies Institute to take part in a study on statins. So in order to try and help people of my own age, I thought, fine, I'm pretty fit. I've been doing gym for four years. I've lowered my weight to a good level, and I do a no-carb diet. So I thought this would be interesting to see how I go. Then, as a preliminary to getting into the study, I thought I'll do a bit of research on the internet, and I was horrified to learn what I did about statins. Heart problems last week. I already had this information on board. I didn't quickly run out and try and find the information. I already had an incredible bias against taking statins. Dr Bishop asked me, quote unquote, to humour him and take them, which I have done for the last week or more, up until the procedure of my stent was put in. You're welcome to talk to me as I'm here. Yes, yes. It doesn't have to be an interview, so we're just going to record it. So, Michael, look, that's great. Can I just check the Menzies researcher that you were going to do? Did you end up taking a statin? No. So? They asked, because it was either placebo or statin, but they asked me to continue in the scheme, which I have done, as a non... A non-taking participant. Sure. So they're measuring my cognitive deterioration or whatever and other health issues by interview. Okay. So you haven't taken a stand. That's important to know. But you're on one now. I am now. And I'm guessing you're feeling okay at the moment. Absolutely no side effects at all. That's great. Well, let's park that for the moment. When you did your research, what would you say was the biggest concern you had about taking a statin into the future for you? Probably my biggest concern and my biggest scare was that I accompanied a mother through dementia for the last 10 years of her life, and it was pretty shocking. The handout given by the Men's Institute said that possibly statins helps avoid dementia. But all the information on YouTube is exactly the opposite. And I thought for a start, the misrepresentation of that information I thought was inappropriate. So I was a bit annoyed about that. And maybe I can... The logic of the situation where the reduced, radically reduced cholesterol to the brain is basically starving the brain of what it essentially needs. So I can't see the logic of how possibly statins can help you with any cognitive function, let alone... you know, the possibility of developing dementia. Maybe I won't. Maybe I'll take after my father. But if there's anything I can do, I would rather risk anything than develop dementia. OK. So I'm happy to speak to those points. What I'll say before I speak to the issue of dementia, though, is that the stuff on the internet is often biased and it's often louder. out of proportion than what it should be. And what you'll notice is that there's people with individual opinions and perspectives who want that heard, sometimes because, maybe like me, I've written a book, so I've actually put information up there, but I'd like to think that I'm a reliable source because if I'm not a reliable source, I'll lose my position on the Hart Foundation, I'll lose my association with the Menzies, I might be confronted by APRA for being beyond guidelines, and I could lose... what my livelihood is but there are people who have made a business out of creating if you like controversy around statins and those people are really loud and you see it in politics in other areas and so sometimes that bias gets lost and sometimes the search engines in google don't allow you to actually find the right information and so that's That's really why I think information is incredibly important. That's why I'm really grateful you've taken the time to let us record this. So what I'm going to put to you is that I think that some of the information you've received is probably not the way I'd view the literature. And the way I've reviewed the literature is in a space where I've been responsible for looking after people for about 15 years. I provide input into a Heart Foundation board. I provide input into a... into the Australian Lipid Guidelines, which are currently being written. We'll come back to where the literature is, but first of all, with regard to dementia, I think it's a really important issue. The FDA, a number of years ago, because of concerns and reports of people describing issues with memory, the FDA did a thorough review of statins and found there was absolutely no evidence from any of the studies that there was any decrease in mental cognition from using the standings. None. And that was over many trials. FDA is American, is it? Yeah. And in fact, it's quite important to get that because the FDA did the same with Vioxx, which is a COX-2 inhibitor, about five or ten years ago, and they pulled it. And the consequence of that was huge amounts of litigation against the company that produced Vioxx. So the FDA are fairly important in terms of creating that possibility for litigation. You can imagine the litigation downpour, the lawyer feast if there was clear evidence that statins caused cognitive impairment. To speak to a couple of your points there, look, the... The amount of cholesterol your brain needs is also misrepresented a bit. First of all, we're not even aware that the statins cross the blood-brain barrier, which is a, if you like, a mechanism that keeps certain things within the body, but not within the brain. So we're not even sure the statins get into the brain, actually. So we don't think that makes a difference. But secondly, if you want to look at absolute cholesterol levels, and we'll take... Yours, I think, because we've got them here. Before any therapy, yours were... Actually, you might be able to tell me. 4.1 total. So let's go LDL cholesterol. LDL is 2.4. Okay, so LDL of 2.4. So we talk about LDLs as doctors. In Australia, our current secondary prevention LDL lowering... objective is about 1.8 millimoles per litre. So 2.4 is higher than what we would think and without getting into too much data around the evidence that's available there's almost no question that the LDL hypothesis holds to some degree such that people are of high risk who've had an event as you lower their cholesterol you lower their risk. So the Australian guidelines are to aim for LDL lowering to 1.8 millimoles per litre. This is not what you previously published in your book. You published less than 2.5. Well, the guidelines change, actually. They keep lowering the goalposts to be able to sell more drugs. Well, it's actually based on the research, and so the research has just shown us with... the new lipid-lowering agents, what we call the PCSK9 inhibitors, that we can get cholesterol levels down to 0.6 and 0.7 millimoles per litre, which is a fraction of where you are, nearly three to four times lower than where yours is, and still demonstrate benefit for individuals with a high likelihood of plaque regression. Now, a reasonable question that you alluded to is how low is too low? Well, it's a really important statistical figure to realise that at the time you're born, your average LDL cholesterol is 0.6 or 0.7. And so at the very time that you are probably most metabolic, you're growing the fastest, your brain is the most active, your LDL is 0.6. And so on standard statin therapy, we're getting nowhere down near that. Okay, touché. Good point. So the chance of LDL wiring affecting your brain in that mechanism seems unlikely. It seems unlikely. I can't... You can never be 100% medicine. I would be a prick if I was arrogant enough to say that's absolute, but it seems very unlikely. The flip side is also true, and that's what was in the Menzies stuff. That was what they said to you, that there's a chance... statins can lower the rate of dementia, and the reason is that a reasonable proportion of dementia is caused by vascular events, so cholesterol buildup in the neck or cholesterol in the carotid arteries or cholesterol buildup in the middle cerebral arteries, giving rise to stroke or mini-strokes. And if you can reduce that, you can reduce progression to dementia. I think it's really important that... You also get an overview of how people have side effects to different medications. There is no question that you can have idiopathic responses. So I do have patients who swear blind that when they start taking a statin, they can no longer do the crossword or the Sudoku. No question. That, however, is not replicated across other patients, and it's not a dose-related phenomenon. I have to accept that they have an idiosyncratic response to that. I don't have an issue with that. And we try to find a way to work around it based on their need to take something to lower cholesterol. We also get people who have allergic responses. That's like someone taking peanut butter and swelling up. So that's unpredictable. We also get recognised complications and for statins. One is at an incidence of about 1 in 70,000. a rhabdomyolysis, and that means that the muscles literally melt down secondary to the HMG-CoA reductase inhibitor. This is a scary and a dangerous situation. It is a medical emergency, but it's incredibly uncommon. And then another recognised side effect is really people with aches and pains, and that is a much harder thing to tease out. At the end of the day, and you'll see this in my book, you'll see it on my website, at the end of the day, I think there's a couple of things that we need to agree on. And if we don't agree on those, then we're buggered. The first is, in the secondary prevention situation, where we've demonstrated people are high risk because they've had an event, or in the setting of imaging because they've got high-risk plaque, then lowering cholesterol, based on all the data we've got available, is likely to bring plaque stabilisation and reduce the risk of that person having an event. And so in that situation, whatever we do to lower the cholesterol is going to be beneficial for that person. Statins... are used because they're now so available, they're off-patent, they're cheap, and they work. We also use azetamib, and there are other agents on the market that are going to come. The flip side of that, though, is in the primary prevention role, and this is in people who have not had an event, who just, for example, have high cholesterol. And this is the group... that gets discussed in YouTube and on the internet on a regular basis, where the advocates are saying cholesterol is not a problem. Because there can be people with high cholesterol and nothing in their arteries. There can be people with low cholesterol and terrible arteries. There can be people with high cholesterol and pristine arteries. There can be people with low cholesterol and good arteries. And that's true. Because of its own, cholesterol is a predictor. before we know someone's got high risk, is not a very reliable predictor. So I'm not even an advocate of giving people statins just because of a number on their lipid profile. I want to know what's going on with them. It's really important to tease those out. In your situation at the moment, Michael, you're a secondary prevention. If you'd come to me and said, I want to know what my risk is, based on you reading my book, I'd say, well... A really good way to do that is to do an image of your heart. If you had nothing in your arteries, I'd say, well, I don't think you need to be on a cholesterol-lowering agent, regardless if your cholesterol level right at the moment, or we wouldn't make a strong advocacy for that because the risk-benefit wouldn't be in favour. If you had terrible arteries, then we would have this sort of conversation and say, look, based on the literature that's available, we would be helping you. Does that help? Yeah, it does. But I still think that statins is an extraordinarily effective medication. There's no doubt about that at all. But I just think it's an overkill, a complete overkill, because it deals with as much as research has been done on it. It deals with so many organs and so many aspects of the body. that to just lower cholesterol at the risk of other dysfunctions, I think, is just inappropriate. So for that reason, I'm prepared to risk having a shorter life, considerably shorter life, and have another event, as you call it, than risk side effects. possible side effects that maybe you aren't even quite aware of. I think the drug industry in America, okay, you've pointed out that FDA, as an example, in past examples with different drugs, put themselves in a very vulnerable position to do what they thought was right. But I still think that the The industry is so huge that I am very sceptical about its integrity. Libertol is made by a company which... Can I hold you there? Because I've obviously got other people. We can't go into the integrity of the pharmaceutical industry on this conversation because it's too far. What I can say is I know many guys who are lead researchers. in the space of lipid lowering. I personally know them. I sit and have dinner with them. I go skiing with them. I meet them at meetings because we share that interest and I happen to be invited to some of the meetings that they get to go to. I know that these people have a high degree of academic integrity and I know that these people are... cautious and careful with regard to what they present in terms of what we can see. We can never know everything. The issue of influence of the drug comp is a different story altogether. I'm not entirely comfortable with that, but it's the world we live in. Yeah, absolutely. There's no question. So the nice thing about the statins at the moment is they're all generic, but let's put the drug... industry to one side, your biggest concern was function within the body by lowering LDL cholesterol. When you look at it in detail, there's really very little that's affected. LDL cholesterol, if you like, is a byproduct of our metabolism anyway. And so lowering it is just getting rid of a side, really a toxic end product. If your concern is about cellular wall, construction, then I've already indicated that at the time you were growing your very fastest, your cholesterol was much, much lower. So 0.6 millimoles per litre, I just want to get you below 1.8. So I don't think there's, we don't think that there's going to be any problems with cellular growth or construction, and that's sort of been borne out really in trials. When it comes to hormonal variances, and you see this on YouTube, Google sort of stuff, the lowering LDL is going to muck up your testosterone, et cetera, et cetera. Well, LDL is not what the steroid hormones are produced from. They're produced from HDL, and HDL is barely affected by statins. So we're not really, we don't have any good evidence that that's the case either. We've done millions and millions of people who've been looked at closely for statins. And if anything, there is a clear signal that we can increase the rate of development of diabetes. Absolutely no question. But they're in people who are susceptible to becoming diabetic anyway. And so we bring that forward a little bit. That data has been closely looked at as well. And without doubt, in those individuals who are high risk, that... That acceleration of the development of diabetes, which can be treated, by the way, and they were going to get it anyway, is offset by the benefit of the agent. Now, at the end of the day, I can't make you take anything. That's not my role. But I can advise you what I think is best, and I really don't like the idea of people dying on my watch. It doesn't suit. So I can't make you do this, but I can tell you, I think I could answer every one of your concerns. you're feeling well at the moment on the medication, my suggestion would be you stick on it for now. And I'm very happy in a month or two or whatever to have this conversation again because I just don't want to see you have an event that could be avoided through lack of me giving you the information you need to make the best decision. Because you've formulated your decision so far of stuff that has really been unfiltered. It's actually the very stuff that's led me. to start to do these podcasts and do my website and create the Healthy Heart Network, because that misinformation is leading to poor outcomes for people. And the really disappointing thing is not only are people getting poor outcomes, but most doctors don't actually know the whole story. I would like to think I'm across all of that, just because it happens to be my area of interest. So I think... And I really am incredibly grateful you came in and said, look, you don't want to take the tablet, I want to talk about it, because I've had people who come off their agents and they turn up in A&E with chest pain and, you know, it's a much easier conversation because then they take it subsequently, but that's running an unacceptable risk in my opinion. I'm going to have to wrap it up there in the interest of time. Thank you very much for the discussion. Can I just confirm you're happy for me to put this up on my podcast? Absolutely. If it's useful to someone, absolutely. Michael, I really do appreciate you. You've been listening to Warrick Bishop and a patient. Michael, thank you for joining us on this podcast and I really hope you've got something positive from it. Goodbye for now. You have been listening to another podcast from Dr. Warrick. Visit his website at drWarrickbishop.com for the latest news on heart disease. If you love this podcast, feel free to leave us a review.
