AMA #2 - What to Ask Before Getting a Stent or Bypass with Dr. Robert Todd Hurst, MD, FACC, FASE

Dr. Robert Todd Hurst (0:02)

Hi, I'm Dr. Robert Todd Hurst, and here's what's coming up on today's podcast.

Rob Hurst (0:06)

From your standpoint, Dr. Hurst, what would you need to see before you could confidently make a determination on whether they need a medication or not? How does inflammation contribute to heart disease? Speaking of procedures, a lot of questions around, there's not a lot of outcome benefit for stents and bypass and people who have stable and asymptomatic coronary artery disease.

Why are those procedures still being done?

Dr. Robert Todd Hurst (0:30)

Do you want the cynical answer or the not cynical answer? Hi.

Hi, this is Dr. Hurst. Welcome to The Healthspan Podcast, where we talk about building your system to add healthy, strong, mentally sharp years to life. On today's podcast, we're going to cover things like, when do you really need a cholesterol medication? What can inflammation and LP little a tell you about your risk? And what should you ask before agreeing to a stent or bypass? And if you would like to be part of these webinars in the future, check the show notes to sign up for our next one. Today's podcast will be moderated by Rob Hurst, who leads our new member advisor team. Rob, what's our first question?

Rob Hurst (1:15)

So we got this from several people, and they were asking about, when is a statin or just any cholesterol medication necessary?

And we've seen people with very high cholesterol numbers who weren't making artery blockage and people with optimal numbers who were. So from your standpoint, Dr. Hurst, what would you need to see before you could confidently make a determination on whether they need a medication or not?

Dr. Robert Todd Hurst (1:41)

Yeah, so this is a really common, I guess, misperception both for doctors and for patients in regards to cholesterol and treatment of cholesterol. So, you know, and it's a little bit built into the way we describe things. You know, statins are often called cholesterol medications and they do lower cholesterol. But I think a better frame around this is really, you can't interpret a cholesterol unless you know that individual's risk. So as you alluded to earlier, you know, I have some patients who have shockingly high cholesterol, like 99th percentile cholesterol, but they don't make artery disease. We've done CT angiogram of plaque composition, zero plaque. We've looked at their carotid arteries, zero plaque. And in that situation, I don't treat their cholesterol because they're very low risk. On the flip side of that, I just saw a young man who has an LDL cholesterol that is in the 80s, on no treatment. That would be a great cholesterol by everybody's measure. But he has aggressive artery disease. He has a lot of artery disease. So in him, his cholesterol is too high for him. So now when we have identified that somebody makes artery disease and their cholesterol is higher than would be ideal for their situation, the next step is, okay, how are we going to lower that cholesterol?

And the reason that we want to move to that is because we know unequivocally, LDL cholesterol, maybe more accurately, ApoB, is a driver of artery disease. It's causative. It doesn't mean it's causative for you. It doesn't mean that that's your driver of artery disease. But for many people, if they are ignoring their cholesterol and they are at high risk for artery disease or have artery disease, they're likely missing a really important opportunity to save their lives. I just state it directly. So, what are those tools? Of course, it could be nutrition. It could be physical activity, sleep, stress, supplements. All those things are potential tools to improve cholesterol and lower risk. The problem with most of those, or at least most people, is that they don't respond very much to those. Whether it's supplements or whether it's nutrition, a strategy, I won't say never, because some people do, but I'd say it's more like 10, 15% of people actually can move their cholesterol significantly based on whether on a nutrition, physical activity or supplement approach. So, in the situation where somebody says, like, I've done everything I can, lifestyle, we're not getting the numbers that we need to get. Fortunately, we have tools, medications, that are generally very, very safe and very, very effective at stopping and even reversing artery disease. Statins is one of those tools, not all of the tools, they are one of the tools. So, I think statins have a bad name for a good reason in some ways. I think that they've been over-prescribed.

People at low risk but high cholesterol, they're given a prescription for a statin. Well, you need to take a statin. Well, do you really? Maybe not. Do you know your artery disease? Do you know what they look like?