Choice of the Heart

Dr Ambrish Mithal is chairman and head, Endocrinology and Diabetes Division at Medanta, The Medicity, Gurgaon
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Don’t take chances if you are in the risk group

JUST LAST MONTH, a 40-year-old business executive reported to our emergency room complaining of nausea and shortness of breath. She had first tried to treat herself with antacids for several hours. She was taking treatment for diabetes irregularly, and had the usual stressful lifestyle of a modern- day metro dweller. Although she denied chest pain, tests revealed evidence of a heart attack. She recovered safely after an emergency procedure.

Her story tells us several things. First, people with diabetes are at two to four-fold greater risk of heart attacks, often at a young age. Second, the presence of diabetes negates the relative protection that women enjoy with regard to heart attacks. Third, often people with diabetes may not have typical symptoms of ‘crushing central chest pain’, so one needs to have a high index of suspicion and seek attention early. Despite considerable medical advances, heart disease continues to be the leading cause of death among diabetics.

Intriguingly, while those with diabetes are more prone to heart attacks, reducing or normalising blood glucose seems to have only a minor effect in reducing the risk. A multi-pronged approach—targeting cholesterol, blood pressure and weight, along with controlling diabetes, seems to be effective in reducing risk of heart attacks. Much of this can be achieved through ‘heart friendly’ lifestyle measures. Replace simple/refined carbs with fibre rich complex carbs and trans-or saturated fats with good fats from nuts like walnuts and almonds. Aerobic exercise for 30-60 minutes a day is essential. Yoga could provide additional benefits. Increased activities make a difference too—climbing the stairs or walking for daily chores. Avoid sitting for prolonged periods. ‘Sitting is the new smoking,’ says the WHO. Get up from your desk every hour to walk to a colleague’s desk or just stretch your body. The West is moving towards standing while working at a desk. On a recent trip to Boston, I visited a doctor who had a treadmill installed behind her desk. She would talk standing, and exercise periodically, in between patients!

Judicious use of medication is also integral to saving your heart. Blood level of LDL cholesterol, the traditional villain (although contested recently) cannot usually be lowered more than 20 per cent despite lifestyle changes. The most popular cholesterol lowering drugs, statins, inhibit an enzyme that is responsible for cholesterol synthesis, and have several other cardio-protective actions. From 1985 onwards, statins underwent numerous ‘double blind randomised placebo controlled’ trials where neither the patient nor the doctor knows whether the patient is receiving the drug or just a placebo. These trials were carried out at multiple locations across the world so that a single centre couldn’t influence outcomes. In several of these trials involving individuals at high risk of heart disease, statins were shown to reduce the risk of heart attacks by about 40 per cent. Soon statins became an indispensable part of any cardiac or diabetes prescription. Yet, almost three decades after their initial use, questions are being raised about statins. Some experts feel their benefits for low cardiac risk individuals have been overemphasised and their side effects—muscle pains (rarely actual muscle damage) and increased risk of developing diabetes—have been underplayed. Since, as is usual for most drugs, statin trials have been funded by statin manufacturers, the media was quick to latch on, and allegations of bias started flying around. The bad press from 2013 onwards led to an estimated 200,000 people discontinuing statins in the UK alone, which could potentially lead to 2,000 heart attacks. There could not be a better (or worse) example of the impact of irresponsible health reporting. In September 2016, the reputed British journal Lancet sought to put an end to this controversy, stating that the benefits of statins far outweigh the risks. If we treat 10,000 patients for five years, 500-1,000 heart attacks can be prevented, whereas only 10-20 people will develop diabetes in a year.

What should you do? If you have had a heart attack (or a stroke) in the past, it is mandatory to take statins. If you are at high risk for these conditions (high LDL cholesterol, diabetes, high blood pressure, a family history of heart disease, or are a smoker) and have been prescribed statins, please do not discontinue. Most people with diabetes should take statins, unless they develop muscle pains. If, on the other hand, you do not have any risk factors, ask your doctor if you need statins at all. But in any case, do not stop taking them on your own.

In matters of the heart, it doesn’t pay to take chances.