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Heart Attack and Stroke Risk

July 6, 2014

CADCardiovascular disease (CVD) is the leading cause of death and disability. More than 60% of us will have a cardiovascular event in our lifetime and one in 3 of us will die of cardiovascular disease, such as heart attack or stroke.

What is your risk?

Doctors calculate the CVD risk in men between age 40 and 75, and women between age 50 and 75. Patients who have cardiovascular risk factors are screened earlier.

The risk calculation includes a cholesterol (lipid) blood test. Fasting for lipid tests is NOT required.

I use the following calculators to assess risk:

1) http://chd.bestsciencemedicine.com/calc2.html?basic=true , OR

2) http://www.qrisk.org/ ( for patients with chronic kidney disease)

 “A risk calculation should be the start of the discussion, not the end of one.”

Calculating a person’s predicted 10-year risk is a probability. It is far from perfect** but serves as a catalyst for dialogue. The risk equation is helpful to start a conversation about your personal preference regarding risk management.

What can you do to protect yourself?

MEDITERRANEAN DIET 

The Mediterranean diet can reduce your risk of heart attack and stroke by up to 30%.

EXERCISE 

Exercise can reduce your risk of heart attack and stroke by up to 25%. Recommendations are for at least 150 minutes weekly (or 30-60 minutes four to seven times a week) of moderate or high intensity exercise (moderate intensity includes brisk walking).

 

SMOKING CESSATION 

If you stopped smoking 5-10 years ago you can be considered a non-smoker for the purposes of cardiovascular risk calculation.

BLOOD PRESSURE CONTROL

Discuss your targets with your doctor.

DIABETES CONTROL 

Discuss your targets with your doctor.

 

 

ASPIRIN

A low-dose of ASA (Aspirin®) may also be recommended for further risk reduction if you are at high cardiovascular risk (20% or more) or have had a heart attack or stroke. ASA reduces cardiovascular risk by about 12.5% (half or third as effective as statins). Note – ASA can cause bleeding. Aspirin is an add-on to statin treatment (see below); it does not replace the statin.

 

STATINS 

Statin drugs can reduce your risk of heart attack and stroke by 25-35%.

Statins are recommended as the first-line treatment for all patients when pharmaceutical intervention is warranted.

Your first line of defence against heart disease is to make good lifestyle choices. But–despite healthy diets and exercise–some of us remain vulnerable and need a second suit of armour, i.e. a “statin”.

Statin drugs were developed to lower cholesterol levels, but this is not the preponderant reason why they protect us from cardiovascular insult. They do far more than move numbers; they protect our blood vessel walls.

Confusing press reports and terrifying package inserts will continue to colour the public’s perception of statin drugs. But let me, for a moment, draw the outline of the argument. Side effects of statins are rarely life-threatening. The heart attacks and strokes that statins prevent are definitely life-threatening. Our focus should be on reducing heart attacks and strokes and deaths.

This does not mean that everyone should be taking a statin. The benefits of statins in research populations are real but these benefits are not guaranteed for an individual.

Harms associated with statins include muscle and liver injury, and elevation of blood glucose levels. Common side effects associated with statin use include muscle aches, but serious adverse effects are exceedingly rare. To keep the risk of developing type II diabetes in context, approximately one patient will be diagnosed with diabetes for every two to 15 patients avoiding CVD or death.

Statins have varying intensities, based on type and dosage.

Low Intensity:  Pravastatin 10-20mg; Lovastatin 10-20mg; Simvastatin 5-10mg; Atorvastatin 5mg; Rosuvastatin 2.5mg

Moderate Intensity: Pravastatin 40-80mg; Lovastatin 40-80mg; Simvastatin 20-40mg; Atorvastatin 10-20mg; Rosuvastatin 5-10mg

High Intensity: Atorvastatin 40-80mg; Rosuvastatin 20-40mg

The benefit of taking any type of statin is greater than the benefit of taking a high versus low dose statin. Therefore, starting and staying on a statin is most important.

Who will benefit from a statin?

There are certain people (high-risk patients) who should strongly consider using a statin because there is substantial evidence to suggest that the benefits of the drug far outweigh the risks for them. These groups are:

1. Those with blood vessel disease (atherosclerotic cardiovascular disease) e.g. people who have had a heart attack or stroke;

2. Patients with a 10-year CVD risk of > 20%. We strongly encourage using statins (preferably high intensity) in this group;

3.   Patients with a 10-year risk of 10-19%. Here we discuss and offer statins (preferably moderate intensity).

It must be said that different practitioners and different countries employ different variations of the above. I believe that all these practitioners are well-meaning. No doctor gets compensated for writing a prescription. We give you information and try to direct your choices in accordance with your own set of values and preferences. Remember, the word doctor is derived from the Latin verb docēre which means ‘to teach’. Sometimes we will make strong recommendations, sometimes we will make weak ones but the decision to follow these recommendations is–and will always be–yours.

The bottom line here is that we are all at risk for cardiovascular disease. Calculating your risk is the first step. Next, you need to decide what steps you are comfortable taking in order to mitigate that risk.


 

**There are other pieces of information that will modulate your risk, such as family history, a coronary artery calcium score greater than the 75th percentile for your age or over 300 Agatston units , a high-sensitivity C-reactive protein level over 2.0 mg/L, or a low ankle-brachial index (< 0.9). It is best to discuss benefits and risks with your family doctor or primary care provider.

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