Chasing Life

Hey there, welcome to Paging Dr. Gupta. Thank you so much for joining us. As you hopefully know by now, this is the show where we dig into the questions that you are sending in, that you were writing in from all over the country, frankly, all over world. And these episodes are some of my favorites because I get to hear from you. I get hear your questions, but so many of you share your stories as well, which I really appreciate, and things that you're trying to make sense of. And with that, our producer Kyra is back with us. What do we have first?

Hey, Sanjay. Okay, so first up, I'm actually gonna be asking one of my own questions. So I just saw these new cholesterol guidelines that came out, and we're hearing that millions more people could be told to start treatment earlier, like in their 30s. I'm almost 30, so I had a mildly alarming thought. Like, am I already supposed to be thinking about statins? I think a lot of people assume high cholesterol is something that you worry about later in life. But now we're hearing something a little bit different. So Sanjay, what are these new recommendations actually telling us?

Okay, Carrot, well, first of all, I think a lot of people had the exact same reaction I've been talking to people around the country, but also people in my own hospital, doctors trying to make sense of all this. And I think the headline here is, don't panic. These new recommendations are about catching risk earlier before bad cholesterol has had years and years to build up in your arteries. So after the break, we're going to talk about what has actually changed and who really needs to pay attention. Stay with us.

'Alright, so new guidelines, 123 pages of new guidelines which I have read and I want to give you some of the headlines first and then dig a little bit into it in terms of trying to make sense of it for you. For years, a lot of cholesterol decisions were based on a 10 year risk of having some sort of heart problem or a stroke. Okay, so typically around age 40, people would really start to dive into these risk factors, and they would ask the question, what is the next 10 years look like for you? What is your risk over the next 10 years? What these new guidelines do is push that conversation earlier. So instead of waiting until 40, the recommendation is to start thinking about screening and in some cases treatment beginning around age 30. So everything frame shifts 10 years earlier and also instead of thinking about just next 10 years thinking about 30 year risk or even lifetime risk. And the idea is that even if your 10 year risk was low, if you have high levels of bad cholesterol and your body is increasingly exposed to that high cholesterol, that can be a problem. That can be an opportunity for plaque to build up in your arteries and potentially cause problems later on. When I have to summarize these guidelines, what they're really saying is that an LDL, that's low-density lipoprotein, that's the bad cholesterol. If it's 160 or higher, if you have a strong family history of premature heart disease, and you have high long-term cardiovascular risk. So first of all, turning 30 does not mean everyone suddenly needs a statin. That's not what they're saying. But it might mean that millions more people who previously were not on medications might be getting a recommendation from their doctors about potentially taking one. But overall, I think the biggest headline here is to think about screening. A lot of people just don't simply know their numbers at all. And you want to be thinking about these numbers as early in life as possible. How early? Well, according to these guidelines, they're saying between the ages of 9 and 11. So 9 years old to 11 years old. That is the first time you should probably get at least one comprehensive screening of your cholesterol and your lipids. Then again at age 19, right as you come out of adolescence and every five years after that. And then at age 30, getting all these numbers checked, but also calculating your risk based on something known as a PREVENT calculator, which you can find for free online. And that's going to give you a good sense really now of what your risk is over the next 30 years to the rest of your life. Again, not everyone's going need a statin by any means, lifestyle changes might still be the right answer for the majority of people, but this is something to start thinking about earlier. Now as I mentioned a lot of questions coming in on this, Kyra, what do we have next?

All right, next up is Juan in Florida, who wants to know will doctors begin to incorporate testing Lp(a) levels for their patients?

All right, I'm so glad this question about Lp(a), Lipoprotein(a) or Lp little (a), that's the way it's often referred to, I'm still glad there's questions coming in about this because this is really important. This may be the most important thing you learn overall from these guidelines. Because a lot of people know cholesterol, they know bad cholesterol, they know triglycerides, but you may have never heard of Lp(a). It's a cholesterol particle. It's similar to LDL cholesterol or the bad cholesterol, but Lp little (a) is stickier. Okay, think about it being stickier and something that's able to build up in arteries and increase your risk of having some sort of heart problem. But here's the really interesting thing about Lp(a). It's largely genetic. That means it's fixed. That means that lifestyle factors like exercise and diet, or lack of exercise and diet, won't really change Lp little (a). It's pretty static, which means you probably only need to get it checked once in your life. It's not really gonna change over your life, so why do you want to test for it? And about 20% of the adult population in the United States has elevated levels. If you have high levels of this, that might push you to reducing your other cholesterol levels even more. So let's say you're sort of borderline with regard to your bad cholesterol. But you have a high Lp little (a), your doctors are more likely to be aggressive in terms of lowering your cholesterol. Now, if you have low Lp little (a) and your borderline, the doctors may say, hey, look, let's try lifestyle changes more aggressively and see if we can avoid taking a statin. But one thing to keep in mind, statins as well as lifestyle changes, they're not gonna lower your Lp little (a). Again, that is largely genetic. That is largely fixed. There are specific drugs that are being investigated nowadays to try and lower Lp little (a), but they're not out as of yet. Alright, now a lot of people hear statin and they immediately understandably worry about side effects. Coming up, we'll get into what is real, what is rare, and what you should actually know. That's after the break.

All right, I hear the pager again. Kyra, who do we have next?

Okay, Sanjay, we have Ryan from California asking, how common do each of the side effects from statins occur?

'All right, common side effects from statins. First of all, let me just dial back for a second and talk about this whole concept philosophically. If you think about the fact that we're gonna be screening earlier and potentially putting people on statins earlier, that's a concern, right? That means a lot more people may be getting medicated. A lot of people will stay on those medications for a long time, if not their entire life. And I just think as a society, we always need to be judicious about adding more and more medications to the mix. Now, in terms of specific side effects, the most reported side effect is muscle pain, muscle aches. Now, on clinical trials, the percent of people who experience this, relatively small, between 5 and 10%, sometimes that muscle pain can be significant enough that people actually want to stop taking the medication. They simply can't tolerate it. Increasing your blood sugar, that's another known side effect and part of the issue here is that statins seem to make you insulin resistant. So your insulin, which lowers your blood sugar, is not working as well. So insulin resistance leads to hyperglycemia, high blood sugar, and in some cases could tip people over into diabetes, less than a 1% chance of that happening. I will tell you just something in general about side effects, people report different possible side effects, all those are looked at. There was a great article about this in the Lancet. So there were 66 possible side-effects that were reported from people who started statins. They take a look at those side effects they compare that to the general population of statin users and the general population overall. And when they do that, they find that there were four things that were real. Other things were more artifacts. The four things that were real, again, muscle pain we talked about, hyperglycemia, elevated blood sugar, and then changes in liver function and kidney function. But beyond the muscle pain, the risk of the other things was pretty low, again less than 1%. When you start statins, your doctor will likely say, hey, before you actually start taking the medication, let's check your liver function for those liver enzymes. And then again a few months into taking the statins. They'll probably want to check again. Even though the risk is low of having some sort of liver problem, that's an easy test to perform to make sure your liver is not taking a hit from these new medications. Okay, Kyra, time for one more question.

So last up, we have Takbir, who takes a statin, and he says he follows his doctor's advice on exercise and diet, but wants to know if he will need to use it for the rest of his life or until bringing the cholesterol to lower limits.

Well, first of all, Takbir, I just want to say that lifestyle changes, diet and exercise, are still going to be the gold standard in terms of the advice you're going to get. It's not going to help with Lp little (a), that is largely genetic, but lifestyle changes exercise and diet can make a difference for a significant percentage of people who are trying to lower their cholesterol. And even if you start taking statins, you should still be implementing lifestyle changes. So question, will you have to be on a statin for the rest of your life? The short answer is typically most patients are, especially those who are taking statins to reduce the likelihood of having another heart attack or stroke. So that means this is secondary prevention. They've already had a heart attack and now they're taking statins to prevent a second heart attack. That secondary prevention population, most of those people stay on statins for their whole life. There's another group of patients who are using it for primary prevention, which means they've never had a heart attack or stroke, they're now using the statin to prevent that from happening in the first place. And again, the vast majority of those people will be on these medications for the rest of their life. When I looked up the most recent data, they found that about one in 77 people are able to come off the statins. And in those cases, it's because their cholesterol levels go low when they stay low, even when the statins are removed. So there you have it, new guidelines for heart disease. And keep in mind, heart disease is still the biggest killer of Americans, men and women alike. So this is a big deal. I think one of the headlines you should take away from this is Lp little (a), Lipoprotein(a), maybe something you've never had checked. Get it checked. You only have to have it checked once because it is genetic, it's not likely to change, but that can influence a lot of the other decisions we've talked about today.

'And that is a wrap for today's episode. Thank you so much to everyone who sent in the questions. This show would not exist without you and I'm glad you're part of it. No question is too big or small. No question is embarrassing. We might just answer whatever's on your mind in our next show. Record a voice memo, email it to pagingdrgupta@cnn.com, that's Paging Dr Gupta at CNN.com. Or give us a call 470-396-0832 and leave a message. Thanks so much for listening.