Improving ‘Statin’ Compliance among High-Risk patients
The Internet has empowered us with easy knowledge and given everybody a voice. Thanks to Google, we can become instant scientists, medical people, political analysts and anything else you want to be. So, when a 64-year-old patient walked into the office for his follow-up with a sheaf of printed sheets downloaded from a Google site, I wasn’t surprised but what he told me wasn’t encouraging.
“I stopped the Lipitor you gave me,” he said. “It is messing up my memory.”
“How can you stop the drug? You had a heart attack and angioplasty a year ago and you have high cholesterol. You know the statin drugs like Lipitor keep your bad cholesterol (LDL) down and prevent further heart attacks. You are a very high-risk patient,” I said.
“But what about my memory problem?”
“Oh, come on Jack, what if you can’t remember everything, you are not an astrophysicist or atomic scientist. It’s normal to have a little memory loss as you get older. But you can’t stop your Lipitor, you’re inviting disaster,” I warned him. Since he has established coronary atherosclerosis, it is reasonable to assume that he may have some early vascular dementia, common in such people. I have my own ‘senior moments’ too, I confessed. But one cannot stop a lifesaving drug like statin that prevents further heart attacks and sudden death. Consulting Dr. Google for knowledge is one thing but acting on what it says without permission from the treating physician is not acceptable.
Which brings me to the most important point of this discussion. Compliance with statin therapy is critical for primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD) that leads to heart attacks and strokes. Statins, as you already know, are a group of drugs like Lipitor, Crestor, etc., that reduce your LDL and help retard the progression of ASCVD. So, it’s critical for high-risk patients to take them to keep their total cholesterol / LDL within the prescribed guidelines of AHA – less than 200/100 in high-risk people (ideally for everybody) but below 180/70 for very high-risk patients, unless there are serious side effects. The most recent reports suggest that the lower the LDL, the better the long-term health. So, do not stop statins if you are already on it without your doctor’s permission.
Another problem we face in clinical practice is that many patients with or without heart disease eligible to receive statin therapy are not getting it, a cause for great concern. According to the recent data from the National Health and Nutrition Examination Survey, a significant majority of the ASCVD events could be prevented by implementing the AHA-recommended cholesterol guidelines in all untreated, statin-eligible people. Many of us Indians and nearly all middle-aged diabetic patients belong to this category, being of very high risk. One study says that physicians fail to prescribe statins in 2 out of every 5 of these diabetic patients under their care! As you well know, LDL – the basic substrate needed for atherosclerosis – falls significantly with statin therapy in the right dosage.
“The relationship between lipids, particularly LDL cholesterol, and ASCVD is strong, graded, and unequivocally causal. Heart attacks rarely occur in populations with extremely low lipid levels, even if people smoke,” said Professor Ian Graham, chief of Cardiovascular Medicine in Trinity College, Dublin, and chairperson of the ‘guidelines task force’ of European Society of Cardiology (ESC) during the recently concluded 2016 ESC Congress in Rome. “Lipids are probably the most fundamental risk factor for ASCVD,” Graham said.
Dr. Chris Cannon, professor of Cardiology from Harvard, echoed the same feeling during his address. Cannon emphasized the global implications of making sure physicians follow through with prevention, and suggested how important risk stratification is. He also explained the prevalence of under treatment, particularly in the United States, and stressed the significance of open communication with patients.
Patients who have even mildly elevated cholesterol – and there are vast numbers of them among us – should be appropriately treated and this includes lifestyle changes and statin therapy. Those who cannot tolerate statins have another option now. The new class of drugs on the market is called PCSK9 inhibitors – a biological type since they are monoclonal antibodies – that have been shown to dramatically lower LDL levels. It is a costly drug, given as injection once or twice a month but most patients that we see in practice can be controlled with statins, especially the more powerful ones like Lipitor and Crestor. Improving compliance with statin usage should be a top priority for every physician.
U.S. FDA approves SMILE: For your EYES only!
No, I haven’t changed my profession. I don’t do teeth.
This column is still related to latest advances in eye care and as I continue to enjoy my passion to help people see, here is another milestone in Lasik surgery.
SMILE stands for Small Incision Lenticule Extraction surgery where instead of a large Lasik flap (like in traditional Lasik), a small Laser incision is made and a refractive lenticule (imagine your prescription being sculpted to a thin wafer) in the cornea that can be actually removed to make you see without glasses.
Simply put, SMILE offers all of the advantages of LASIK like quick visual recovery, and stability) while avoiding most of the potential downsides of LASIK flap creation. These can include weakening anterior corneal collagen (due to cutting of collagen fibers), cutting corneal sensory nerves, which contribute to "dry eye" symptoms after LASIK, risk of ripples or wrinkles in the flap that may require subsequent care, and others.
It is an all laser technique with no blades and high accuracy where the laser sculpts the front and rear surface of a tiny lens-shaped section of corneal tissue, then create a keyhole incision to remove this “refractive wafer” from within the cornea. All of it within minutes.
I have had the privilege of experience in performing this technique abroad before FDA approval and it is one more option in today’s world for appropriate candidates.
Anatomically and physiologically, there are many proposed advantages of SMILE over Lasik:
Gentle and less visually obtrusive than Lasik;
Comparatively safer than Lasik;
Less flap-related complications;
Better preservation of corneal nerves compared to Lasik, so less chances of "Dry Eye" symptoms as seen after Lasik;
The biomechanical strength of the cornea is higher since it preserves the forward-most corneal collagen;
Many patients with high Myopia (Nearsightedness) can be candidates for SMILE when Lasik is not an option.
Though I am positive about its approval in the United States, I reiterate as I have in all my previous columns to ensure you don’t fall for any advertisements. First, meet with your eye doctors and let them decide what technique is best for you.
There are about 18 laser vision techniques and more than 10 lens-based techniques along with innumerable combination approaches to custom design surgery for your eyes individually. You deserve the technique and technology best suited for your eyes and vision goals.
Sure SMILE, great times are here!