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. Dr. Warrick Bishop and I'd like to welcome you to my podcast station. Thank you for tuning in. Today I'd like to talk about cholesterol, the confusion and the controversy surrounding it. Well of course on a regular basis I see patients in my rooms and we talk about cholesterol management and we talk about statins and from time to time I've had some feedback from patients who have formed opinions based on information they've been able to obtain through their own research, most commonly through the internet. I've generally spoken with these people one-on-one and gone through their particular needs and their particular situation, and that's worked very well, and I haven't thought too much about it. In 2018, however, I put together a Facebook group. That Facebook group is called Know Your Real Risk of Heart Attack and I put that Facebook group together to provide a reliable source of information for patients. Something that I hoped that could inform and educate those patients to make sure they were most understanding of medical issues related to the heart to improve the questions and the understanding. of their own condition that they may have and therefore improve their outcome. Our Facebook group covered all sorts of topics like heart attack prevention. In fact, that's where it started. But we covered things like atrial fibrillation and funny beats of the heart. We talked about family history, blood pressure, stents and bypasses, even supplements. But the thing that was most striking was the... discussions around cholesterol and statins. Within that Facebook group, there were a few members who had incredibly strong views about cholesterol and its role in heart disease and statins and their role, or not, in preventing heart disease. It became rather difficult because some of the members in that group had such fixed opinions that there was no opportunity for discussion. They were clearly polarised and clearly passionate about their position. They were adamant cholesterol was not important in heart disease and they were clear that they did not believe statins had a role nor did they work. And worse than that, statins had unacceptable side effects. which were anything from loss of memory to cancer to putting on weight to depression. These discussions really just became too heated from one particular member of our Facebook group called Jeff. Jeff had had an experience through the healthcare system in regard to his heart and he had dedicated nearly the last decade of his life to looking into heart disease and some of the other theories and considerations around it. The difficulty that we found within that Facebook group is that Jeff was good enough to be active and he was good enough to post, but really he continued to post over and over and over again similar, related, posts which all were suggesting cholesterol was not important in the development of coronary artery disease and that statins were of no benefit. Well, I guess that begs an interesting question, which is how, when we know what the current convention is about heart attack, when we know that there's a whole body of literature and guidelines supporting the use of lowering cholesterol and treating people with coronary artery disease with statins. How can there be such a polarised opinion out there, even by an individual who is not a medical person? I'm happy to accept people get their own information and education. I think that's really important. But where did Jeff get this information from? And the really big question is how can his information, his truth, match up with the truth that I bring to my clinic every day? Well, that's what I want to try and cover in this brief podcast. The answer in understanding the difference between current guidelines surrounding treatment of cholesterol and treatment of heart disease versus Jeff's opinion is understanding the difference between association and causation. I'm going to tease that out a little bit with a simple example. Let's consider car accidents as our example. We would all agree that speeding and alcohol are... clear-cut associations to an increased risk or likelihood of having a car accident. But we can also all agree that just because you speed or just because you've consumed alcohol, it does not mean you will have a car accident. Therefore, speeding and alcohol are not causative. They are associated. Well, let's bring that back to hearts. Let's accept that cholesterol is an association. Well, we see people with high cholesterols who go through their whole life and never have a heart attack. Okay? Perhaps cholesterol isn't important. But we see people with low cholesterols who have heart attacks. Okay, maybe still cholesterol is not important. But we know if we take a group of people with high cholesterol and follow that group for 10 years versus a group of people with low cholesterol and follow that group for 10 years, when we compare those two groups, then the people with the higher cholesterol levels have a higher rate of heart attack. So I can assure you there is an association between cholesterol and heart attack when we look at it on a population basis. This means that cholesterol is an association and not necessarily a causation. And so Jeff, to his credit, when he said cholesterol didn't cause coronary disease, had some... reason for saying that and some accuracy in presenting that position. However, we know that if we take those people with high cholesterols across the board and lower their cholesterols into the future, we can reduce their risks of heart attack in the future. This again supports that cholesterol is not causative. but it is an association. So let's move from just dealing with cholesterol to if we deal with people who we know are truly at high risk because there's a build-up of cholesterol plaque within their arteries. There is no question within the literature that's available and been building on over the last 30 to 40 years, That if we look at people who are truly at high risk, then lowering their cholesterol using medications gives a better result than not. What's not clear cut is if we take low risk patients who, for other reasons, may have no other issue other than an elevated cholesterol. we know that treating those people may not necessarily lead to a significant reduction in their outcome. So, when we're considering the role of treatment in lowering cholesterol, we need to take into account whether the patient is clearly a high-risk individual or a low-risk individual, We need to take into account issues regarding side effects of the medication, the sort of targets we would be hoping to treat to, other risk factors that that individual might have, which includes such things as blood pressure, smoking, diabetes, degree of exercise, and these issues are best discussed with your GP. In summary though, if you have had a heart attack or a stent or a bypass, then all the data we have available is very reassuring that lowering your cholesterol will improve your outcome, whether your cholesterol is high, low or in between at the time that you start treatment. Given the body of literature we have available today, there's no question that the statin drugs are effective and safe in that role and provide excellent efficacy and excellent outcome benefit. The situation is a little bit different if you have high cholesterol only. and you are otherwise fit and well, then some guidelines would recommend that very high cholesterol levels of their own should be treated. But if your cholesterol is high, then perhaps, before treatment, a good, clear discussion with your general practitioner, or, if possible, a specialist who's interested in cholesterol, which is called a lipidologist or a preventative cardiologist, may be a valuable thing to do. Either your GP or the specialist in particular may suggest that you're a candidate for considering a test to actually look at the health of the arteries. A way we can scan the arteries and check and see whether there's a build-up of cholesterol there or not. Of course, if there is a... buildup of cholesterol in your arteries, then treating the cholesterol makes perfect sense. If there's no buildup of cholesterol in your arteries, then treating the cholesterol aggressively may be something that you can discuss in more detail to find something that suits you and fits with your best outcome objectives. I actually cover a fair bit of that information in a free TV series. that I've made available on my website, so please feel free to use that for more information. In the meantime, as always, I would love to wish you the very best in health. Take care, goodbye, and thank you for joining me. 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.
