People who have multiple risk factors for heart disease (such as smoking, obesity, lack of exercise, elevated cholesterol, diabetes, hypertension) often fail to get the right kind of "coaching" from their doctors. Here's DrRich's take on what you should do if you find yourself in a high-risk category.

Studies in the past have shown a correlation between low LDL cholesterol levels and the risk of cancer. Whether this correlation is merely an association or a cause-and-effect relationship has remained unclear. That is, whether low cholesterol increases the risk of cancer, or whether cancer lowers cholesterol, has not been sorted out

But as a result of this association, a persistent question has been whether lowering cholesterol levels with statins (which, in appropriately selected patients, will significantly reduce the risk of heart attack and death), will increase the risk of developing cancer. We discussed this issue here last summer.

This week, researchers published a major study in the Journal of the American College of Cardiology looking at whether statins increase the risk of developing cancer. The conclusion: they do not.

In this study, the incidence of cancer in over 51,000 patients treated with statins was compared to the incidence in over 45,000 patients treated with placebo. While lower LDL cholesterol levels in this study correlated with a higher risk of developing cancer, thus confirming the association seen in previous studies, the investigators were able to conclude that treatment with statins did not increase that risk. That is, patients whose cholesterol levels were lowered by statins had approximately the same risk of cancer as patients not treated with statins who had higher cholesterol levels.

The results of this study should go a long way toward allaying the fears of those who have been concerned that statins may increase the risk of cancer. However, this study represented a meta-analysis of many other studies which were not designed to specifically answer this question, so its results – while very comforting – cannot be considered definitive.

The question of when and whether to use statins is addressed here.

_Sources:

Alsheikh-Ali AA, Trikalinos TA, Kent DM, Karas RH. Statins, low-density lipoprotein cholesterol, and risk of cancer. J Am Coll Cardiol 2008; DOI: 10.1016/j.jacc.2008.06.037.

The COURAGE trial, first reported in 2007, showed that patients with significant coronary artery disease and stable angina had similar outcomes (that is, a similar risk of heart attack or death) whether they were treated with aggressive medical therapy or with stents. (Read about the COURAGE trial here.)

A new quality-of-life (QOL) analysis from the COURAGE trial has just been published in the New England Journal of Medicine. This latest analysis shows that QOL was substantially improved whether patients received stenting or medical therapy. While gains in QOL were somewhat higher with stenting than with medical treatment, that difference lasted for only a year or two. By year three, QOL was the same in both groups.

Critics of the COURAGE trial point out that drug-eluting stents (DES) were not used in this trial, and that in the real world many patients treated medically for angina are not treated optimally. However, DES create their own special dilemma (which critics of COURAGE seem reluctant to mention), and it somehow seems self-serving for cardiologists to default to stenting because doctors (quite often the cardiologists themselves) fail to give optimal medical therapy.

The bottom line: The QOL analysis of the COURAGE trial supports the initial conclusions of the study as reported in 2007. Stenting does not offer any improvement in mortality or heart attack prevention over optimal medical therapy, and any differences in QOL between the two forms of therapy are transient.

So: In patients with stable angina, it is quite reasonable to try optimal medical therapy as the first step. If optimal medical therapy fails to adequately control symptoms, then stenting can be done as a second step.

_Sources:

Weintraub WS, Spertus JA, Kolm P, et al. Effect of PCI on quality of life in patients with stable coronary disease. N Engl J Med 2008; 359:677-687.

Boden WE, O'Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007; 356:1503-16.

A new study shows that smoking is the major cause of heart attacks in people under 40 years of age. Read what this means - for younger smokers, and for those not so young - here.