Inflammation and Increased Risk of Cardiovascular Disease

For years, experts have noted that up to 50% of men who have a heart attack do not have diabetes, high blood pressure, high cholesterol, do not smoke and are active. This has led to an exploration of other causes and risk factors of cardiac and cerebrovascular disease.

In recent years, studies have shown an increased risk of cardiovascular disease in patients with rheumatoid arthritis, in untreated psoriatic arthritis and in severe psoriasis. We can also add atopic eczema to the list of cardiovascular risk factors.

In a publication in the British Medical Journal, investigators noted that patients with severe atopic eczema had a 20% increase risk in stroke, 40 – 50% increase risk of a heart attack, unstable angina, atrial fibrillation and cardiovascular death. There was a 70% increased risk of heart failure. The longer the skin condition remained active the higher their risks.

The study looked at almost 380,000 patients over at least a 5 year period and their outcomes were compared to almost 1.5 million controls without the skin conditions. Data came from a review of medical records and insurance information in the United Kingdom.

It’s clear that severe inflammatory conditions including skin conditions put patients at increased risk. It remains to be seen whether aggressive treatment of the skin conditions with immune modulators and medications to reduce inflammation will reduce the risks?

It will be additionally interesting to see what modalities cardiologists on each side of the Atlantic suggest we should employ for detection and with what frequency? Will it be exercise stress testing or checking coronary artery calcification or even CT coronary artery angiograms? Statins have been used to reduce inflammation by some cardiologists even in patients with reasonable lipid levels? Should we be prescribing statins in men and women with these inflammatory skin and joint conditions but normal lipid patterns?

The correlation of inflammatory situations with increased risk of vascular disease currently raises more questions with few answers at the present time.

Men’s Sexual Function Tied to Statin Use

Statins v2Statin medication has been used for years to lower cholesterol and reduce an individual’s risk and chances of having a heart attack, a stroke or symptoms of peripheral arterial vascular disease. The “off label” uses of statins have been noted by many practitioners and researchers as well. The Bale and Doneen research team have for years believed that statins stabilize soft lipid plaque in the wall of blood vessels and reduce sudden heart attacks and strokes by reducing inflammation. At the American College of Cardiology meetings recently a paper was presented and appeared in the online version of the Journal of Sexual Medicine hinting that statins improved erectile dysfunction. John Kostis, MD, of Rutgers Robert Wood Johnson Medical School in New Jersey said that statins improvement of erectile dysfunction was about 1/3 of what pills like Viagra, Levitra or Cialis can achieve but significantly better than placebo or life style improvements. He felt the improvement in erectile dysfunction was due to the medications lowering of lipid levels and to their improvement of the endothelial cells that line the inner walls of our blood vessels.

For many years erectile dysfunction was felt to be a marker for cardiovascular disease because it was felt that the ED reflected an inability to achieve adequate blood flow in the vascular tree of the genital organs. Testosterone, the male hormone, is a byproduct of cholesterol metabolism. It was originally felt that by lowering cholesterol you were indirectly lowering testosterone levels and this might affect your sexual performance. This study in 647 patients enrolled in 11 randomized studies with different statins would tend to reach a different conclusion that by lowering the lipids and maintaining the blood flow you can actually improve erectile function despite lowering the testosterone indirectly.

Dr. Kostis was quick to point out that statins should not be used as a sexual enhancing drug in men with normal or low cholesterol levels. He called for a larger study looking at multiple statins versus placebos and the current ED meds on the market.

Statin Use and Diabetes in Older Women

Older women who take statins may be at an increased risk of developing Type 2 Diabetes Mellitus (adult onset). In a study published in the Archives of Internal Medicine, Dr Ma, of the University of Massachusetts School of Medicine, looked at the 154,000 women in the Women’s Health Initiative who did not have Diabetes when the study began in 1993.  Seven percent (7%) of them were on statins at the time through follow-up, 12 years later.  At that point, 10,242 cases of new cases of diabetes were reported. They theorize that this computes to an almost 50% increase in becoming a Diabetic if you are on a statin as compared to women who are not. Surprisingly, this occurred far more frequently in thin women taking a statin than in heavy or obese women.

The salient points taken out of this research are that women on statins need their liver enzymes monitored frequently they need their blood sugars monitored as well. The overriding message is that as physicians and patients we need to make a monumental effort to control elevated lipids by diet , exercise and weight loss without statins if humanly possible.

This also raises the question of whether we should be measuring HDL and LDL subtypes an Lpa levels on all patients before instituting statin therapy?  While this raises doubt about a popular class of drugs that are a crucial part of the prevention of cardiovascular disease, it does not yet make it clear what the clinical implications are for postmenopausal women on statins.

I will reevaluate all my female patients on statins as I see them for follow-up visits.