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What will lower heart disease risk?

Bupa investigative news - 29 November 2002
written by Rachel Newcombe, Bupa health news reporter

Cardiovascular disease refers to any disease affecting the heart, blood vessels and blood circulation, such as heart attacks or strokes. In the UK, cardiovascular disease kills roughly one in three people, with people over the age of 65 being particularly at risk. A recent study has shown that folic acid may lower this risk, while another study has shown that statins - cholesterol-lowering drugs - could benefit older people. However, an American doctor has put forward a controversial view that statins may actually cause more harm than good. So, what is best for lowering one's risk of cardiovascular disease?

K E Y    P O I N T S

Homocysteine is an amino acid found in the blood - raised levels cause heart disease.

Folic acid reduces levels of homocysteine and could cut the risk of stroke and heart disease.

Drugs called statins are have been successfully used since 1996 to help middle-aged people who have heart disease and high cholesterol.

One American doctor has claimed that statins may be dangerous and may even cause heart failure.

British experts disagree and say there's overwhelming evidence to support the benefits of statins. In addition, a study has shown that elderly patients could benefit from taking statins too.

What were the headlines?

Cardiovascular disease research has provoked a number of headlines, including "Folic acid could cut stroke and heart attack risk", "Folic acid could save lives", "Drugs can help older hearts, too" and, controversially, "Is drug that combats cholesterol dangerous?".

The first three headlines were generated by two studies that were published in the British Medical Journal and The Lancet resectively. One study that suggested that folic acid could cut the risk of strokes and heart disease by up to a quarter. The other showed that elderly patients could benefit from taking statins, a class of drugs that are widely given to middle-aged patients with cardiovascular problems.

However, the final headline "Is drug that combats cholesterol dangerous?" was produced in response to the confusion caused by an American doctor who claimed that statins could have dangerous side-effects. This controversial view could potentially cause worry to millions of people who are taking these drugs.

What is the bigger picture?

The study suggesting the benefits of folic acid was published in the British Medical Journal (BMJ). Dr David Wald, from the Department of Cardiology at Southampton General Hospital and two colleagues from Barts and the London School of Medicine, analysed 72 studies about the association between a naturally occurring amino acid called homocysteine and cardiovascular disease.

They discovered a "strong link" between high homocysteine levels and an increased risk of heart disease. Because the B vitamin folic acid can reduce levels of homocysteine, the researchers suggest that taking folic acid supplements could reduce the risk of heart disease by 16 per cent, stroke by 24 per cent and deep vein thrombosis by 25 per cent.

Dr Wald believes it is a significant finding. "Everyone over 55 years old and, in particular, anyone with diabetes and existing cardiovascular disease should consider [taking a folic acid supplement]. It would be effective, inexpensive and safe," he said.

The study into treating elderly patients with statins was published in The Lancet. It was led by Professor James Shepherd, from the University of Glasgow, and looked at the effects of a statin drug called Pravastatin in nearly 6,000 men and women aged between 70 and 82 years old. All the participants had cardiovascular disease or had a high risk of developing it. Half the group were given a 40mg-a-day dose of the drug, while the others received a placebo.

The researchers found that cholesterol was lowered by a third and reduced a combination of coronary death, non-fatal heart attack and strokes by 15 per cent, when compared to the people who weren't given the drug. The drug was most effective in reducing death from heart disease, which was cut by up to 25 per cent.

The findings not only back up other large trials of statins that show beneficial effects, but also show that older people would benefit from these drugs too. Professor Shepherd said, "There is clearly no justification for withholding statins from the elderly."

"I think it's highly likely that folic acid supplements could cut the risk of heart disease. The statin research is very significant because it actually tested statins in the age group that has the burden of disease, where statins are potentially very helpful. People needn't worry about the CoQ10 theory - it was a very small trial and much more research is needed."

Dr Virginia Warren,
assistant medical director
Bupa

However, Dr Peter Langsjoen, an American cardiologist, has disagreed with mainstream opinion by suggesting that statins could actually cause heart failure. He says that statins deplete the body of co-enzyme Q10 (CoQ10), an antioxidant that is vital for heart health. He carried out a tiny pilot study and says: "This is not a theoretical problem - it's real and being ignored."

Although this suggestion sounds alarming, the study was very small and Langsjoen is still waiting for funding for larger-scale research. At the moment, the existing evidence from large-scale clinical trials that show the benefits of statins are much more convincing, something even Dr Langsjoen admits. "Although our small pilot study is worrisome, it is certainly not strong enough to convince other physicians," he said.

Dr Langsjoen also explained that heart problems due to lack of CoQ10 are "more notable in settings of pre-existing CoQ10 deficiency, such as in the elderly and in heart failure". This could suggest that CoQ10 problems are due to increasing age and illness, not the drugs themselves.

ACTION POINTS

Increase your intake of folic acid by eating plenty of foods rich in this vitamin.

Reduce your risk of cardiovascular disease by eating healthily, not smoking, losing excess weight and exercising regularly.

If you're concerned about dietary issues, speak to your GP or a nutritionist.

What does this mean?

Bupa's Dr Virginia Warren believes it's "highly likely" that folic acid could help reduce heart disease. "I also think it's quite likely that people might need to be taking B12 and B6 as well," she said, adding that it's not just the over 55s who could benefit, as "they're applicable to people of any age".

Alison Drugan, a cardiac nurse at the British Heart Foundation (BHF) agrees. "It is already known that folic acid can lower raised levels of homocysteine in the blood and this report lends more support to the theory that it could, therefore, help prevent heart disease," she said.

Experts welcomed the positive news about statins, particularly because the trial involved elderly people - the age group who could benefit from the drugs. "The trial is very significant," said Dr Warren, adding that it's likely doctors will consider prescribing the drugs to older patients.

Belinda Linden, head of medical information at the BHF, agreed. "There has been a need for clear evidence," she said. "This paper provides this evidence for the first time and will hopefully ensure that, in future, this group of patients can safely take statins."

But British experts aren't convinced by Dr Langsjoen's ideas. Dr Tim Bowker, associate medical director at the BHF said, "This new information should not change practice on statin prescription. What we do know, as a result of several large clinical trials, is that for people with heart disease the benefits of taking statins far outweigh the risks - they are living longer and are less likely to have repeat heart attacks."

What does this mean to me?

People prescribed statins should carry on taking them, says Dr Warren. "We've got overwhelming evidence that they're overall beneficial." If you want to discuss it with your doctor, she advises bringing it up the next time you have a routine check-up.

It may also be a good idea to increase the amount of folic acid in your diet. "I think it's certainly a good idea to ensure people have a good amount of folic acid in their diet," said Rhoda Sutherland, a state registered dietician at Bupa Hospital Chalybeate in Southampton.

"Folic acid is found in fruits and vegetables, nuts and pulses. Eating the recommended five portions of fruit and vegetables a day is associated with a decreased risk of some cancers and heart disease," explained Gail Goldberg, a nutritionist and spokesperson for the British Nutrition Foundation.

And finally, if you're concerned about cardiovascular disease, there are a number of ways you can reduce your risk. "Stop smoking, as it depletes the body of the antioxidant vitamin C," says Rhoda, "Increase your intake of antioxidant vitamins A, C and E through eating fresh fruit and vegetables. Also, lose weight, adopt a low-fat diet and get plenty of exercise."

Summary

Cardiovascular disease affects thousands of people, but statins have successfully been used with many patients since the mid-1990s and it's their use could now be extended to include older people too. It's helpful to have a good intake of folic acid, but the issue of whether statins could have a detrimental effect is questionable.

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