21 November 2019
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Hypertension, not cholesterol, is the key cardiovascular risk factor

Dr Ross Walker
29 August 2019

There is no doubt that certain aspects of cholesterol and fat metabolism are important factors in the generation of heart disease but, it is my opinion that the place of cholesterol as a risk factor in heart disease is overemphasised by the medical profession. For many years, I have been saying that I do not treat cholesterol but rather cardiovascular risk. The only people who should have their cholesterols lowered, in my opinion, are people who have already suffered a heart condition, such as a heart attack, stent or coronary artery bypass graft or have proven atherosclerosis in other regions such as the cerebral circulation or the legs. The only other group that needs cholesterol lowering are people that have a high coronary calcium score.

In October 2015, the Journal of the American College of Cardiology released a large study of 5000 people over 10 years of which 77% of the people in the trial fitted the US criteria to be on a statin for high cholesterol levels. But, half of those people had a 0 coronary calcium score and their event rate was so low over the 10-year period that the conclusion of the trial was that statins were worthless for people with a low or 0 coronary calcium score.

But there is no doubt that hypertension needs to be treated at all times regardless of vascular history because of its potential to contribute to cerebral haemorrhage, stroke, atrial fibrillation, heart failure and chronic kidney impairment. A recent trial of 9000 people followed for 3 years known as the SPRINT study targeted half the patients to a blood pressure level of 140/90 and the other half to 120/80. This study clearly showed that lowering the blood pressure 120/80 reduced the risk for heart attack, stroke, sudden death and heart failure by around 30%.

A recent sub-study from the same trial published in the Journal of the American Medical Association looked at blood pressure control in midlife and the risk for cognitive impairment and potentially dementia later on. They collected 450 brain scans from people with an average age of 50 and looked at the white-matter lesions which are the connecting neurones within the brain. This study found that those people who were targeted to a blood pressure of 140/90 compared with those targeted to 120/80 had a significant increase in white-matter lesions which is a potential marker for cognitive impairment and dementia in later life.

A prior study showed that aggressive management of blood pressure led to reduced cognitive impairment.

When considering blood pressure management there are 5 lifestyle factors:

  1. Reduce abdominal obesity. Less than 95 cm waist circumference for a male and less than 80 cm for a female
  2. 3-5 hours of moderate exercise on a weekly basis
  3. Avoid sugar and salt
  4. Keep alcohol consumption to less than 3 standard glasses/day
  5. Stress management

There are 3 natural substances with an evidence base for blood pressure management:

  1. Kyolic age garlic extract
  2. Bergamot polyphenolic fraction-47% polyphenol extract
  3. 2 small pieces of dark chocolate daily greater than 70%

The final major factor related to the generation of high blood pressure is sleep apnoea. If you are waking unrefreshed and feel tired throughout the day, you should consider an evaluation for this condition and have this treated.

Despite all of the above therapies, many people need pharmaceutical treatment. The pharmaceutical management for hypertension, in my view, has been one of the major advances in medicine over the past century with a very strong evidence base and safety profile. I have a number of patients in my practice who for some reason are against using pharmaceutical therapies but this is one area where the medical science is absolutely solid and irrefutable. As hypertension is the major cardiovascular risk factor worldwide, proper management would see the rates of all forms of vascular disease plummeting.

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