Erin D. Michos, MD, MHS, associate director of preventive cardiology at Johns Hopkins Ciccarone Center for the Prevention of Heart Disease and associate professor of medicine at Johns Hopkins Medicine, both in Baltimore.
Bottom Line: “Good” cholesterol isn't so good anymore—but here’s what is
Heart disease remains the number-one killer of both men and women in the US today, so prevention is paramount. But conflicting news stories make it tough to figure out what to do. Should you take a baby aspirin…a fish oil supplement…a statin? Since everyone is different, is the risk for some people actually overblown? Here’s what’s true about preventing heart disease…what’s false…and how to know what you should do…
Myth: A baby aspirin a day keeps heart disease away. A number of recent studies conducted at major medical research institutions have confirmed that most healthy people without known heart disease shouldn’t be taking daily aspirin to prevent heart attacks. The ARRIVE trial looked at more than 12,500 men (age 55 or older) and women (age 60 or older) who were at moderate risk for heart attack, while the ASPREE study included more than 19,000 healthy, low-risk adults over age 65. Both studies were designed to determine whether a daily low-dose aspirin would prevent a first heart attack or stroke. Not only did the low-dose aspirin not reduce that risk in either study—it also increased the risk for major gastrointestinal bleeding. Even more alarming, in ASPREE, the group randomly assigned to take aspirin experienced more deaths from cancer. Important: Aspirin still is recommended for patients who have had a heart attack already to prevent a second one. But if you’re healthy and popping a daily aspirin, my advice is to ask your doctor about stopping your aspirin.
Myth: Over-the-counter omega-3 supplements prevent heart disease. A recent review of major studies found that over-the-counter supplements did not reduce the risk for heart disease or stroke in the general population.
But one type of high-dose omega-3 prescription drug may help certain patients. New research: The REDUCE-IT trial, conducted at Harvard Medical School, studied Vascepa, a purified form of eicosapentaenoic acid (EPA) given in a high dose (4,000 mg) to patients already treated with statins who were at high risk for cardiovascular disease or diabetes and who had high triglyceride levels. In early results, Vascepa reduced cardiovascular events such as heart attacks and strokes by 25% over five years. (The full results will be presented at the American Heart Association annual meeting in November 2018.) While this may turn out to be an effective prescription for certain patients, these results shouldn’t prompt healthy people to take over-the-counter fish oil supplements.
Myth: The higher your level of HDL “good” cholesterol, the more protected you are from heart disease. HDL is the so-called “good” cholesterol because it helps remove “bad” LDL cholesterol from your bloodstream. And studies have found that people with high HDL seem to have lower risk for heart disease. But new research casts doubt on whether it’s truly protective. Example: No drug therapies that boost HDL have been shown to reduce heart disease risk.
And too high a level of HDL actually may be harmful. Two recent studies have shown an association between very high levels of HDL (above 80 mg/dL) and increased heart attacks and death from all causes. We don’t know why this is, but it may be that very high HDL indicates that your HDL is not functioning properly. Until more is known, focus on the heart disease risks that you can control, such as increasing physical activity, optimizing body weight and keeping triglycerides, LDL cholesterol, blood pressure and blood sugar under control.
Myth: If your cholesterol is too high, you need a statin. Actually, some people with high cholesterol don’t benefit from a statin—and some people with low cholesterol actually do. While high cholesterol, especially “bad” LDL cholesterol, is a major risk factor for heart disease, it’s not the whole story. Many other factors matter—age, gender, race, blood pressure, family history and whether you smoke, have diabetes or are sedentary. So doctors evaluate your overall risk factors for heart disease to help determine whether to treat you with a statin. They do so by calculating your 10-year risk of having a heart attack or stroke. A score of 7.5% or higher means that a statin is “recommended”—whatever your cholesterol number.
Even if your score is 7.5% or higher, however, you still may not need a statin. Why? The calculator, developed by the American Heart Association and the American College of Cardiology, may overestimate risk, some studies find. What to do: If your score is high, ask your doctor about a coronary artery calcium (CAC) scan, which detects calcium deposits in arterial plaque. If your CAC score is zero, there’s no need for a statin. If it’s high (typically 101 or above), that means you have a high risk for heart disease, and a statin generally is recommended. What if it’s in the middle, between one and 100? That’s a decision to make with your doctor, considering your other risk factors—along with your personal preference about whether you want to start taking a statin.
Myth: Reducing inflammation is a healthy goal, but we don’t know whether it will reduce heart disease risk. Actually, we do. Cardiologists have suspected for some time that chronic inflammation—a state in which your immune system is in overdrive—can fuel the development of clogged arteries (atherosclerosis)…and trigger plaque to rupture and cause a heart attack. But we didn’t know until recently whether tamping down inflammation could really help prevent heart attacks and strokes.
Now we know that it can. Last year, the CANTOS study, conducted at Brigham and Women’s Hospital in Boston, showed that canakinumab, a type of drug called a monoclonal antibody that reduces inflammation, reduces the risk for a new heart attack or stroke by a significant 15% in people who already have had a heart attack.
While the drug still is experimental (and likely will be very expensive if/when it’s FDA-approved), the good news is that we already know how to substantially reduce chronic inflammation with healthy habits. These include not smoking…keeping your waist size no more than 40 inches for men and 35 inches for women, regardless of your body weight…eating a Mediterranean-type diet…exercising regularly…getting six to eight hours of sleep every night (the sweet spot for heart health)…and reducing stress (meditation, yoga).
Myth: Unless I have diabetes, my blood sugar levels won’t affect heart health. Blood sugar that’s consistently even just a little above normal means that you have prediabetes. As a result, you’re not only at greatly increased risk for diabetes but also heart disease. It’s a wake-up call to improve your lifestyle, including weight loss (often losing 10 pounds is enough to bring blood sugar back to normal)…increasing dietary fiber…eliminating sugar-sweetened drinks and processed meats…and exercising. Simply by taking a 30-minute daily walk, you can reduce the risk that prediabetes will turn into diabetes by 30%.