The Latest ACC/AHA Cholesterol Guideline: A sea change

Cholesterol check

Photo Credit:  Stuart Miles/freedigitalphotos.net

The American College of Cardiology/American Heart Association published their latest cholesterol management guideline last month. It is a complete change of the prior American guidelines that aim at a particular cholesterol target.

First of all, it recommends treatment for the 4 groups of patients:

1. All who already have heart disease, stroke or peripheral blood vessel disease (“cardiovascular diseases”)

2. Everyone with diabetes between 40-75 years of age

3. Those with an LDL (bad) cholesterol of 190 mg/dl (5.0 mmol/l) or more

4. Those with a calculated 10-year risk of cardiovascular disease of 7.5% or more.

Secondly, they suggest using only statins, and no other cholesterol-lowering medication.

Thirdly, they recommend stopping the routine monitoring of cholesterol levels after treatment, because of the lack of evidence.

Lastly, they place far less emphasis on additional screening tests such as hsCRP, a mark of inflammation in the body and cardiovascular risk

Since then Dr Nancy Cook and Dr Paul Ridker had published an article in the New York Times that call into question the calculator used, unusally before their critique paper in the journal Lancet has been published. Cook and Ridker pointed out that the calculator overestimates the cardiovascular risk in their own data set of patient population. Dr David Goff, co-chair of the guideline committee, explained that the population set used by Cook and Ridker are more recent and those patients have reduced risk probably because they are volunteers, and might have already taken statins and so their risk became lower. Interestingly, Goff was also puzzled by Ridker’s lack of comment in 2012 when the guidelines were sent to Ridker, and revealed that Ridker’s suggestion to use hsCRP in the risk calculation was rejected. Ridker receives royalties as co-holder of patent on hsCRP, which is a blood test used for risk-stratification for cardiovascular risk.

Hmm. I had not seen a guideline critique being so personal before. Previously, lead authors exchange disagreements in the journals, in an usually courteous manner.

The American Association of Clinical Endocrinologists had just rejected the guideline. They disagree with removing the cholesterol targets, the out-dated risk calculator, and the omission of medication other than statins in lowering cardiovascular risk.

Do we doctors agree on anything now about cholesterol? Well there are:

1. High cholesterol is associated with blood vessel blockage (atherosclerosis), heart attacks and stroke.

2. Lowering cholesterol generally lowers that risk. Most studies were done on statins, but other studies on other medication, such as niacin,  fibrates and Vytorin, had also shown benefits before.

3. The relative benefits are rather constant. So patients with high risk benefit more. For example, if a patient has a 50% risk of having a heart attack in 10 years, lowering the cholesterol can reduce the risk to 25-30%. So 1 in 4 patients are saved. But for a low risk person with 1% risk of having a heart attack in 10 years, lowering the cholesterol reduce the risk by 0.4-0.5%. So 200 people needs to be treated before one is saved.

4. All cholesterol-lowering medication has a small risk of side effects. Muscle ache, increased liver enzymes, and diabetes are the commonest.

Ultimately, it is best that you discuss with your doctor whether you need treatment. You should ask about the benefits and the risks of taking the drug.

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Avoid Glibenclamide for patients who are elderly or have renal failure

Finger prick meter

Photo credit:  Gualberto107/freedigitalphotos.net

Glibenclamdie (glyburide in America) is a common and useful drug for type 2 diabetes. It is effective and the blood sugar lowering effect long-lasting. However, the strength is also a weakness: it can sometimes be so powerful that the patient can suffer prolonged hypoglycemia (low blood sugar level).

The Health Sciences Authority of Singapore had looked at the data and found that in Singapore, patients who are above 60 or those with kidney failure have a much increased risk of severe and protracted hypoglycemia. They have now advised all doctors to avoid using glibenclamide in those patients.

There are many other alternative drugs in the same class such as gliclazide and they are also generics, available at a low price at our clinics.

If you are taking glibenclamide and had recently turned 60 or have renal failure, please do not stop your medicine immediately, but talk to your doctor about it.

Asian Students are tops in Academic Assessment Again!

Asian girl reading

Photo Credit: By Sira Anamwong from freedigitalphotos.net

The OECD has just published the Programme for International Student Assessment (PISA) report. Who are the top 7?

1. China-Shanghai

2. Singapore

3. China-Hong Kong

4. Taipei

5. Korea

6. China-Macao

7. Japan

What do they have in common? A Confucian culture. Even in America, Asian American students do well academically.

Foreigners may not realize how important studying is in the Asian family. Ever since Confucius taught about the importance of studying and opened a sort of a school, Confucian countries have put lots of importance on studying. The pressure is immense. In Singapore it is not uncommon for a parent to take a year off work to help their child to take the primary school leaving exam.The highest scoring candidates in exams become mandarins. Some popular Chinese saying shows how important it is:

1. All trades are lowly except for studying

2. Study hard and you will find great wealth and a beautiful wife in the books

Ahem. Certainly very chauvinistic. But this is ancient China after all.

There is of course a huge downside: children who have poor grades think they are failures. A lot of children, even those who are successful in the system, are burnt out by the time they enter university and end up hating lifelong learning.

Doing well in life requires more than just grades, and it may shock those top scorers when they start working and learn that grit, determination, EQ, connections and pure luck are far more important. I do try to teach my children those things as well.

3 Scientifically Proven Way to Prevent Diabetes: sleep, move, eat

Tsunami

Photocredit: Danilo Rizzuti/freedigitalphotos.net

My article on the Coming Tsunami of Diabetes: how to dodge it has just been published.

Diabetes is an extremely serious problem in Singapore. 1 in 9 adults have it and by 2030, 1 in 5 adults are going to get it.

I personally love the first scientifically proven way: sleeping. Not sleeping enough increases our stress hormones (adrenalin and cortisol) which raises our sugar, and increases our hunger hormone so we want to eat more.

The second is what all doctors say: exercise. I had previously written about the power of exercise.

The third is to eat healthy. Avoid artificially processed starch such as white bread,  white rice and juices. Whole grains should be taken instead. Yes even Michelle Obama supported it.

Remember: sleep, move, eat.

Sweden just endorsed the Low Carbs High Fat Diet

Finally, Sweden has done it: in the latest expert committee convened, it has formally endorsed the low carbs high fat diet. Ever since Dr Atkins advocated the high fat and low carbohydrate diet, many people have used it to lose weight. The only drawback apparently is the boredom: patients are sick at eating cheese omelet every day. Unfortunately, Dr Atkins did not like publishing in main-stream medical journals. It created a management gap on obesity: while patients who went on the diet definitely got impressive results, doctors remained extremely skeptical.

Well for the past 10 years many studies had been done and had all found one thing: low carbs high fat diets are better than the traditionally-advised low fat high carbs diet. Patients lose more weight, has better blood sugar (which we expect) but watch this: patients who are taking a low carbs high fat diet also has better cholesterol levels!

The evidence has been so overwhelming that I am surprised that we doctors have resisted it for so long. Unfortunately doctors are all bound by the Hippocratic Oath which asks us to always respect our teachers. This may sometimes make us unwilling to challenge the “conventional wisdom”.

Indeed for all my patients with diabetes, I strongly advise the low carbs high fat diet. However I advise them to eat the healthier fats such as fats from fish, nuts, olive oil etc. Indeed a very Mediterranean diet which has been shown to save lives.

Nanotechnology to detect blood clots

Photo Credit: Christine Daniloff/MIT

Blood clots in the legs are commonly called the Economy Class Syndrome, whereas passengers in the coach class develop potentially life-threatening blood clots in their legs when they sit around not moving for a long time. The other group of people at risk are patients who just have surgery in the pelvis or legs, and cannot walk around.

Sometimes those blood clots break and travel to the lungs and block the big lung arteries, killing the patient.

Now, a group of researchers led of Sangeeta Bhatia, a doctor and a bioengineer, had found a way to detect these clots early, by using nanotechnology.

Blood clots are rich with thrombin. So iron oxide particles coated with special peptides are injected into mice. Should the particles encounter thrombin, the special peptides react with thrombin, releasing substances that can be detected in the urine. Iron oxide particles have already been approved for human use by the FDA.

At the moment, doctors have to look for late signs of blood clots in the leg which includes a swollen feet, and breathing difficulties (late stage). It is then confirmed by an ultrasound of the leg veins which is labor-intensive. This technology has the potential to greatly help us pick up the blood clots before they arise.

World Diabetes Day Singapore 2013

WDD 2013

Mark the day – 10 November 2013. As diabetes affects 11.3% of Singaporeans, the number of families with one or more members are becoming very high. This year the Diabetes Society of Singapore is going to have an event packed with activities at the Suntec Convention Centre. There are tons of free stuff there:

Free Hba1c test (cost $30)

Free eye photos (cost $30)

Free feet check (cost from $25 at least)

Free consultation with diabetic nurse educators, pharmacists, dieticians (cost from $25 each)

Total free stuff: $160 plus the goodie bag!

In fact since every year the DSS celebrates the World Diabetes Day, you can just get your eyes and feet checked free of charge over there, as they are supposed to be screened yearly as well.

Pravin, a patient with type 1 diabetes will also be there to share his experience. He was diagnosed to have type 1 diabetes at age 7, but had learnt to live with the illness, and is now an engineer. He also runs marathons, climb mountains and volunteers overseas to help other people with diabetes.

So just go to Suntec this Sunday!