The role of Statins in the Athero-Sclerosis, Heart attacks and Strokes

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 The role of Statins in the Athero-Sclerosis,
Heart attacks and Strokes

Lt. Gen. Prof. Emeritus Mahmud Ahmad Akhtar, HI (M)
Formal Surgeon General Army / Principal Army Medical College

Statins are the most effective drugs for the prevention of athero-sclerosis and diseases like heart attacks, strokes and peripheral vascular disease etc. Surprisingly doctors including many cardiologists do not prescribe statins for the primary prevention and even not for the secondary prevention which amounts to medical negligence. Even when prescribed, are not given in adequate doses. It is usually due to lack of knowledge about drugs i.e. the discipline of clinical pharmacology and clinical therapeutics.

Many of the doctors think of statins in term of its actions on lipids only. It should be kept in mind that statins have a number of other life saving actions beyond lipids called “heliotropic effects". They suppress inflammation that contributes to lipid plaque formation, the basic pathological lesion of the coronary cerebral and peripheral arteries; the rupturing of which causes heart attacks, strokes etc. They also improve the function of the endothelial cells in the arteries enabling them to expand as needed. They reduce the size of the plaque, provide stability to plaques, reducing the chance of rupture and heart attacks, strokes etc. They also act on the platelets and the coagulation cascade and the Renin Angiotensin Aldosterone System thus helping in the prevention of disease. Statins should be used for primary prevention in all the diabetic patients, at the age of Forty years in males and Fifty years  in females and earlier if there are other risk factors. Diabetics are at significant risk of having heart attacks and strokes. Risk should be calculated keeping all the factors in view, family history, weight, central obesity, hypertension, intensity of diabetes and its control, lipid profile, activity, smoking and cardiac status etc. 

High intensity statin therapy should be for higher risk and moderate intensity for moderate risk and low intensity for the lower risk. A renowned cardiologist remarked that if he suffers a heart attack in the desert- one drug, the statin he would like to have. We should have department of clinical pharmacology / clinical therapeutics at our institutions. Risk factor should be reviewed periodically and dealt with.

Healthy life style therapy is a must and the most important part of management. Diet should consists of at least five portions of vegetables and fruits (3-4 portions of veggies and one to two portions of fruits, keeping into consideration, weight, lipid profile and calories etc.). Whole grains preferably of low glycemic index like barley, oats, bran, pulses, legume, beans, lentils fiber like ispaghol husk, low fat dairy product, oily fish, chicken white meat without skin, mono unsaturated oils (Canola for cooking, extra virgin olive oil for use on the table), nuts like almonds, walnuts, pine nuts, peanuts, seeds like sun flowers, pumpkins, sesame etc. Enough intake of water, avoiding saturated fats, red meat, sugars (or taking in small quantities depending upon lipid profile) and blood glucose, egg white is good, yellow in moderation depending upon lipid profile and low salt diet etc.  Enough exercise (stretching, aerobic and muscle strengthening, sports etc) according to physical fitness, healthy sleep following the circadian rhythm, keeping healthy mental health, adequate relaxation and recreation, avoiding tensions, conflicts, doing relaxation exercises, meditation, voluntary work, treating mood disorders like depression etc  and avoiding smoking both passive and active. Obesity, particularly central obesity should be avoided. The abdominal girth i.e. midpoint of abdomen between the lower border of ribcage and the upper border of iliac crest should be less than 35.5 inches in males and 31.5 inches in females, even less in short statured individuals. The overall fat should be less than 20% of the body weight in males and 30% in females, LDL should be less than 100mg in diabetics and less than 70mg in sufferers of ischaemic heart disease, HDL above 40 mg in males and 50 mg in females. It is very important to keep blood pressure and sugar levels in diabetes within normal range which unfortunately most often is not done.

There should be regular periodic medical checkups – early detection, early treatment of risk factors, prevention of disability and rehabilitation. There should be emphasis on prevention and health promotion. Prevention is not only better than cure but is the only cure, the real cure. It is cost effective. Vaccination should be kept updated particularly flu vaccination yearly in October/November. It has been found that flu vaccination also lowers the incidence of heart attacks and miscarriages in pregnant women.

Unfortunately Pakistan is having one of the highest incidence and prevalence of communicable and non communicable diseases in the world even amongst the SAARC countries. There should be turn around for the better. Bangladesh has done it is a short span of time. Pakistan can and should do it.