There is some hint that statins may help lower blood pressure, but I would not count on statins to lower blood pressure. In my practice, using a ratio between LDL- and HDL-cholesterol as the measure of dyslipidemia, 50% of men and 33% of women with hypertension have dyslipidemia, and hence should be treated with statins. I am finishing data analysis of about 3500 patients in my practice and will soon be able to update those numbers. I would use statins only to treat dyslipidemai, except in the case of acute atherothrombotic disease (ATD) events, where the liberation of NO at the artery wall induces vasodilatation, which is helpful. I would not advise "Statins for all."

Dear Williams!

Good day. From your discussion interpret statins to be helpful in reducing blood pressure? But do not see them being used in clinical practice.

so do u suggest statins use in subjects with hyperlipidemia or without lipid issues.

Moreover, would this be an independent effect ? Or associated one?

I guess very prolong use with plaque size reduction over years would add to this benefit? Correct me please if they are to be recommended in every hypertensives?

Regards

Can you elaborate further in simplicity?

Regards

There is already a message in circulation like use of loprin and that us "Statins for all" . Are we heading towards that?

There is some hint that statins may help lower blood pressure, but I would not count on statins to lower blood pressure. In my practice, using a ratio between LDL- and HDL-cholesterol as the measure of dyslipidemia, 50% of men and 33% of women with hypertension have dyslipidemia, and hence should be treated with statins. I am finishing data analysis of about 3500 patients in my practice and will soon be able to update those numbers. I would use statins only to treat dyslipidemai, except in the case of acute atherothrombotic disease (ATD) events, where the liberation of NO at the artery wall induces vasodilatation, which is helpful. I would not advise "Statins for all."

Dear Williams

Thanks a lot. Tour incoming data output may elaborate further and yes "STATIN FOR ALL" doesn't suit well for ALL and it has to be personalized.

Regards

Amen!

Dear colleague, you implicate the use of statins in individuals suffering from high blood pressure and dyslipidaemia showing significant atherosclerosis (quote: plaque regression/stabilization); in your reply you state therapy should be advised in individuals suffering from high blood pressure and dyslipiaemia, no word about sign. atherosclerosis; you should clarify this to Mr. Khan.

I would only use statins if the patient has dyslipidemia, regardless of his blood pressure status. And I would rarely use anti-hypertensive agents (CCB's and/or ACEI's) unless the patient's blood pressure is high, though I might lower the treatment threshold if the patient has dyslipidemia that does not respond to treatment. Does this help?

dear colleague Feeman, you state you would use statins in dyslipidaemia....is that in patients showing artherosclerosis/increased intima-media diameter or history of pvad/cvd or even before knowing their cardiovascular status?

I think William has clearly suggested use of statins ONLY in subjects with dyslipidemia with hypertension.

An addition to that could be patients with hypertension and IHD who may need statin to achieve their target secondary prevention goal of 4.0 mmol/L.

Firthermore, I feel everything will finally converge to a single patient level, where the personalized approach should be adopted to add or not to add statins.

Lastly, AHA guidelines (I read 2017 ones) states clearly the recommendations with evidence level about use of statins with associated comorbidity.

Regards

Sorry that I was not more clear. I use statins in a primary prevention scenario--I don't wait until some sort of atherothrombotic disease (ATD) event has occurred. My definition of dyslipidemia is an elevation in the Cholesterol Retention Fraction (CRF, defined as [LDL-HDL[/LDL) or in any event if LDL-cholesterol exceeds 169 mg/dl (when the precipitation method of HDL-cholesterol measurement is used or 159 mg/dl if the enzymatic method is used. This will be a new concept to some of the readers, but it is fully expressed in my publications and presentations noted at my website at www.bowlinggreenstudy.org, which is free and open to all. I do not limit my use of statins to those with hypertension.

Why not simply rely upon non-HDL cholesterol. It has shown better correlation with small atherogenic dyslipidemia.

Benifits of statin therapy in hypertensive patients probably because of its pleotrophic effect not because of its effect on BP reduction. Routine use of statin in all hypertensive patients probably can not be recommended at present but in it can be a possibility in future. There are some suggestions of benifits of statin use in low and intermediate risk patients in HOPE -3 trial. Currently probably hypertensive patients with following risk factors may benifit from statin therapy

Patient with strong family history of CAD

Patient with dyslipedemia

Patient with family history of

premature CAD

Obesity

Sedentary lifestyle

Smoking

Target organ damage

Established CAD

Thanks

A consideration I introduce to this conversation.

The drug company gold mine called statins permanently damage cellular mitochondria. Statins are mitochondrial poisons. ie... you will never see an endurance athlete that is using them. This consideration was experienced, discovered and documented by Duane Graveline, MD, MPH, but, as might be expected because it upsets the Big Pharma statin-vending 20 billion-dollar a year applecart, his work was rejected for publication by the mainstream medical publications, who are beholden and corrupted by money from Big Pharma. However, his data is detailed on his site, Statins and Mitochondrial Damage and in his books.

An acquaintance, a retired senior research scientist, at 58 years of age, used to run 4 miles to work, work out for a couple of hours and then run home. His "cholesterol" went above "normal", which is an arbitrary number with no good data to support the current recommendation. The contrary. (Senior women and men with the highest cholesterol lived longest in studies. https://medium.com/the-mission/higher-cholesterol-is-associated-with-longer-life-b4090f28d96e)

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(97)04430-9/abstract.

His cardiologist (MD) talked him into taking statins. In a few days if he ran 100 yards, he felt "like he ran a marathon."

He reversed this condition only when he began taking C60oo (Carbon C60 dissolved in olive oil), which is the most potent mitochondrial protectant antioxidant that is known - and it is free from toxicity, "...even taken long term..." according to Fathi Moussa, a world authority on C60. (I have taken C60oo since August 2012 and have experienced its beneficial effects. It is a mandatory part of my "anti-aging" supplement regimen.)

I have had several older friend begin taking statins only to experience terrible muscle aches. When one asked her doctor if the statin caused this he replied, "No. You're just getting older." When she quit the statin the pains disappeared. This (and its progression to rhabdomylolysis ) is "reported" to be a "rare" occurrence. I've known six people that have experienced this. Really, how rare is it?

Is the notion that statins permanentaly "fringe?" Only if you are married to Big Pharma and the AHA, who has no credibility after cursing hundreds of millions of people to CVD with their recommendation to eat margarine, rather than butter in the 1960's.

Further, so-called "bad" LDL cholesterol, a statin target, have been shown in a large review to be higher in the longest lived. However, two types of LDL, large buoyant and small particle, have different effects. Large buoyant LDL cholesterol is associated with lower triglycerides. Those with high triglycerides (and low HDL cholesterol) have a six times greater risk of heart attack, than those with low triglycerides and high HDL cholesterol. Small particle LDL are associated with endothelial damage.

There is much misinformation guiding American cardiology.

Recommend statins and do harm. Isn't "do no harm" the medical mantra?

Dear Michael K. Mooney

This is really interesting as i feel if the body has cholesterol than a minimum and maximum range must be defined.

YES very old age is associated with higher mortality once the cholesterol is very low

YES most of the samples coming from serious patients from ICU have very low cholesterol

YES in my lab and clinical practice i had seen people having very low cholesterol especially once they drop below 3.5 and especially once

The question about why I do not use non-HDL cholesterol as my risk predictor was published in June of 2017 in the European Medical Journal. It was also presented at the 2018 symposium of the International Atherosclerosis Society in Toronto in June. Briefly, non-HDL cholesterol, when divided into quintiles, predicts better and better as the quintiles progress from lower non-HDL cholesterol levels to higher levels; however, there are fewer and fewer people in those higher quintiles. The CRF likewise predicts better and better, when divided into sextiles, as the CRF values go from low to high; however, the number of people in the higher sextiles remains relatively constant. And hence, the CRF predicts more people at risk of atherothrombotic disease (ATD). The reason for dividing non_HDL cholesterol into quintiles is that this is the way the NLA said to do it. Moreover at any level of non-HDL cholesterol in the ATD population, a high associated CRF predicts an earlier age of ATD onset, whereas a lower CRf predicts a later age of ATD onset. The data is available at my website at www.bowlinggreenstudy.org, which is free and open to all.

My statin-treated patients, myself included, live a long time. I have been on statins for some 25 years and am now 75 years old. I am doing well, and so are my patients.

A question, Dr. Freeman - do any of your patients or you perform endurance exercises? And if so, what kind? Also, have you or any of your patients noticed a difference in cardiovascular/aerobic endurance or any experiences of muscle aches?

I just finished a 6 minute game of tag-rugby and while I finished the game, I was very tired after the game. Only the other hand, I am 75 years old and I don't think that I did too badly. I do not routinely do exercise tests on my statin patients. And BTW there is no "r" in Feeman.

I follow Sikandar Hayat Khan answer

Participating in a 6-minute game of tag-rugby is great for someone that is 75, Dr. Feeman. That is interesting.

A note of support for statins came from a cardiologist friend. He said that because a majority of his patients will not be compliant with such things as nutrition and exercise, taking a medication is an easy answer that can reduce their cardiovascular risk.

Most people will not get a half hour of aerobic exercise 3-6 times a week or quit eating sugar or other junk foods and adhere to a Mediterranean diet.

Being an outlier, who is extremely compliant, I forget that patient compliance is likely a doctor's biggest problem.

Thank you for your enlightening personal note.

Dear Mr. Mooney, amongst my patient are about 2,5K athletes up to olympic levels, which I visit regularly twice a year. My oldest masterclass athletes are 75 years. I can confirm, that there are about 20-30% of the patients who are treated with statins suffering from muscle aches, high CK levels or even liver enzyme levels. However there's no correlation between CK levels and intensity of side effects. About 15-18% have to drop out of treatment due to lack of fitness and endurance capacity. I have to state that I ONLY suggest treatment after a 3 month period of elimination of highly saturated fats and red meat showing no effect on LDL-Levels. If there's presence of CVD through coronary CT or Angiography showing coronary plaque burden or even high risk lesions with no indication to PTCA/Stenting indications to treatment is clear.

Dr Mooney,

Did I mention that the temperature that day was 92 degrees?

Cheers,

W.E. Feeman,Jr,MD

This will also be relevant among Black Africans as we have found a very large association between hypertension and dyslipidaemia. It is also hoped that the single pill combination therapy will help reduce cardiovascular risks when it eventually becomes available worldwide as many studies in ESC 2018 clearly highlighted.

A ploy pill is simple to take, but does not allow the titrations necessary to optimal risk factor control.

Sorry, I meant polypill not ploypill.

Thanks everyone for the highly educative discussion. The whole concept of treating hypertension is to reduce the global cardio vascular risk. Something beyond the numbers! I believe that all hypertensives except those who belong to the real low risk category hypertensives

Continuation -

All hypertensives except those who come in the real low risk category should be treated with a statin. Whether it should be prescribed separately or as a polypill is a matter of preference by the Physician as well as the patient.

In about a month, the Lancet will publish a letter to the editor from me showing the various ATD risk categories.