Live Web Chat Transcript:
Regression of Atherosclerosis - May 14, 2007

Steven Nissen, M.D.
Cleveland Clinic Heart and Vascular Institute
Chairman, Department of Cardiovascular Medicine
President, American College of Cardiology

Cleveland_Clinic_Host: Thank you for joining us! Today's chat with Dr. Nissen will begin shortly. Please submit your questions by typing them below and then clicking 'Ask'. We'll get to as many questions as we can.

Cleveland_Clinic_Host: Welcome Dr. Nissen and thank you for being with us today. Let's begin!

Research, Clinical Trials, and Innovation

danhamrick: Would it not be helpful to you and to your audience if you brought us up to date first on the status of the current research on reversing atherosclerosis and other heart diseases and disorders?

Speaker_-_Dr__Nissen: That is a very long answer. However, we'll touch on many of the issues of current research in answers to specific questions

lpmulligan: What studies currently under way do you view as the most promising for improving heart care?

Speaker_-_Dr__Nissen: There is a study just beginning known as AIM-HIGH. This study compares a statin alone to a statin drug plus niacin. It is designed to answer the question about the benefits of adding niacin to a statin. We are also doing a study using an experimental weight loss drug known as rimonabant (accomplia) to see if reducing abdominal fat can slow the progression of coronary disease. Results are expected early next year.

Angioplasty versus medications

stephelia: Recent studies have indicated that angioplasty and the use of stents on first heart attack events are a better choice than treating with follow-up medications. Can you clarify if uncoated or coated stents are a better choice?

Speaker_-_Dr__Nissen: During the first few hours after a heart attack the best treatment is placement of a stent to re-open the blocked coronary artery. More recently, there has been a trend toward using a plain bare metal stent rather than a drug coated stent for patients with a heart attack. Research in this area is continuing and practice in this area may change over the next few years

Regression and Reversal of atherosclerosis

muckamuck: I was informed by my physician that regression of atherosclerosis was not possible. Only further damage could possibly be prevented.

Speaker_-_Dr__Nissen: It is difficult to actually remove plaque from the coronary arteries but recent studies have suggested that it may be possible. One of the keys is getting the LDL cholesterol (bad cholesterol) to very low levels.

Speaker_-_Dr__Nissen: Last year we published a study that showed in a group of patients who lowered LDL cholesterol with statin drugs to about 60 mg/dl on average regressed plaques.

Terri: what do you recommend to help reverse heart disease?

Speaker_-_Dr__Nissen: Reducing LDL (bad cholesterol) to low levels is important and is the cornerstone of therapy.

Speaker_-_Dr__Nissen: Raising HDL (good cholesterol) appears to be equally important.

Speaker_-_Dr__Nissen: In addition, regular exercise has been shown to dramatically benefit heart patients.

Speaker_-_Dr__Nissen: And - controlling blood pressure is equally important. If you keep your LDL down, your HDL up, don't smoke, exercise regularly, and control your blood pressure, you have a very good chance to slow or reverse the buildup of plaque in your arteries.

cornybob: Dr Nissen, What is the regression rate once target cholesterol numbers are met?

Speaker_-_Dr__Nissen: in a study we published last year - known as the ASTEROID trial - about 2/3 of patients who achieved an LDL of less than 60 actually showed regression (reduction in plaque in the coronary arteries).

lpmulligan: Are your recommendations for young people to avoid heart disease the same as your recommendations to help reverse heart disease?

Speaker_-_Dr__Nissen: No. In individuals who have not yet developed heart disease the target goals for cholesterol levels are more moderate. In the absence of risk factors for younger individuals a desirable LDL cholesterol is less than 130 mg/dl. IF LDL levels are greater than 160 - 190 some physicians will recommend treatment even for individuals who are otherwise healthy and younger. Some conditions are considered equivalent to already having heart disease such as diabetes. Those patients should get their LDL cholesterol below 100 mg/dl

cornybob: How is it possible to determine regression if the target has been achieved for some years?

Speaker_-_Dr__Nissen: There is no simple test to determine if regression has occurred. In research studies we frequently use IVUS (intravascular ultrasound) but it is an invasive technique and it is not recommended for monitoring therapy.

Diet and Herbals

Terri: I would like to know if you recommend the Dr Dean Ornish program for the regression or reversal of heart disease?

Speaker_-_Dr__Nissen: I do not recommend the Pritikin or Ornish program. This diet involves extremely low levels of fat intake which results in a very high intake of carbohydrate - starches and sugars. There is not good evidence that these very low fat diets are healthy. In fact, most fad diets are unwise including the Atkins diet, the Pritikin and Ornish programs. We recommend a balanced diet that includes healthy fats, such as olive and canola oil, nuts, and other sources. To read more about this - please take a look at the Healthy Heart Lifestyle Guide & Cookbook.

lawrence: Do you think herbal supplements can help in the regression of atherosclerosis?

Speaker_-_Dr__Nissen: Herbal supplements have not been tested by the food and drug administration and are strongly discouraged at best these are worthless therapies and at worst they may be harmful. One exception is Omega 3 fatty acids, which in most studies seem to promote heart health. Specifically avoid products like red yeast rice and garlique, which are heavily promoted but unstudied therapies.

Speaker_-_Dr__Nissen: Always ask your doctor before starting any herbals.

uplands: What are your views on the DASH diet?

Speaker_-_Dr__Nissen: There is no question that the DASH diet, which includes, reducing salt intake and increasing consumption of fruits and vegetables can significantly lower blood pressure. In people with high blood pressure the combination of lifestyle changes with some type of blood pressure medicine can control high blood pressure. In patients with mild elevation of blood pressure, the DASH diet may control blood pressure without the need for any medications. Regular exercise can also be helpful in controlling elevated high blood pressure.

Terri: does wine raise hdl or lower total cholesterol?

Speaker_-_Dr__Nissen: All forms of alcohol in moderation will raise HDL in many patients. However, the amount of increase is small and it is unclear the extent of health benefits. In general, we don't recommend alcohol as a therapy for low HDL cholesterol.

felimbb: Does switching to a vegetarian diet (no meat) help reduce LDL and/or increase HDL?

Speaker_-_Dr__Nissen: A vegetarian diet does not necessarily improve cholesterol levels. It all depends on what type of vegetarian diet. For example, some vegetarian diets can actually be high in saturated fat. It is really about careful choices.

Speaker_-_Dr__Nissen: We recommend diets that emphasize healthy fats such as monounsaturated and polyunsaturated fats. We also recommend avoiding transfats.

Speaker_-_Dr__Nissen: If the vegetarian diet emphasizes these important principles it can be very healthy.

Vulnerable Plaque

lpmulligan: How do you view the possibility of identifying plaques with the mix of fat and a thin cap making them vulnerable to rupture?

Speaker_-_Dr__Nissen: The concept is that certain plaques are more "vulnerable" than others. Identification of such plaques may enable prevention of heart attacks. This is an unproven theory and there has not yet been a technique developed that can reliably detect vulnerable plaques

Raising HDL Cholesterol and Lowering LDL Cholesterol

danhamrick: Aside from exercise and wine, are there other medicines or substances that will raise HDL or lower total cholesterol? I read a book claiming that two supplements, policanisol and gugulipid, would help. Is that supported by any scientific evidence?

Speaker_-_Dr__Nissen: No. Dietary supplements are untested and potentially harmful and should be avoided in most cases. However, it may be useful to discuss this with your doctor

pszych: I have one lad stent. What level of LDL should I achieve?

Speaker_-_Dr__Nissen: For most patients with heart disease, the target LDL (bad cholesterol) is less than 100 mg/dl. However, for very high risk patients, such as those with diabetes or many other risk factors, we are now recommending an LDL of less than 70 mg/dl.

Speaker_-_Dr__Nissen: Please discuss with your doctor if your goal should be less than 100 or less than 70 mg/dl.

danhamrick: Is the lowering of LDL cholesterol with statin drugs to reverse atherosclerosis irrespective of any increase in HDL? Which is more important?

Speaker_-_Dr__Nissen: Both are important. In a recent study we showed that both reduction in LDL and in increase in HDL were approximately equal in importance in reducing plaque buildup in the coronary arteries.

pszych_2: What did the folks in the ASTERoid study last year do to get LDL down to 60.........?????????

Speaker_-_Dr__Nissen: We administered rosuvastatin in a dosage of 40 mg. This reduced LDL cholesterol by 53.5%.

danhamrick: Given your answer about target levels of LDL to reduce plaque, what then would be a target level for HDL?

Speaker_-_Dr__Nissen: We recommend for people with heart disease, an HDL greater than 45 - 50 mg/dl for women and 40 - 45 for men.

Speaker_-_Dr__Nissen: However, higher is even better. Most individuals with HDL levels greater than 60 do not develop coronary artery disease.

caddman11: Is there a way to increase your HDL?

Speaker_-_Dr__Nissen: Exercise and moderate amounts of alcohol can raise HDL a little. If HDL is very low, we often prescribe large doses of the vitamin niacin which can raise HDL 25% or more. This should always be done under a doctor's supervision. The amounts of niacin required are usually in the range of 1500 to 2500 mg.

Speaker_-_Dr__Nissen: I do not recommend taking niacin supplements over the counter without a doctor's supervision.

roaminghermit: What about just keeping total Cholesterol below 150

Speaker_-_Dr__Nissen: We do not emphasize the level of total cholesterol because it is much more important to have a healthy balance between the bad cholesterol (LDL) and the good cholesterol (HDL). If total cholesterol is less than 150, but HDL is very low and LDL is high, then the level of less than 150 is not necessarily healthy.

danhamrick: Can total cholesterol or the ratio of HDL to total cholesterol be too low? If so, what is the limit?

Speaker_-_Dr__Nissen: There is no level of LDL cholesterol that is considered unsafe or dangerously low. Surprisingly some studies have treated patients to LDL levels in the single digits (less than 10) with no apparent untoward effects. Although we don't recommend routinely treating patients to such low levels. Very low levels are not dangerous.

Statins and other cholesterol lowering medications

setexan1: what are the long term effects of taking statins, especially LIPITOR?

Speaker_-_Dr__Nissen: Long term studies of statin drugs including Lipitor showed that these drugs maintain their effectiveness for years or even decades.

Speaker_-_Dr__Nissen: There is not increase in side effects over time. Therefore, patients doing well on one of the statin drugs can almost always expect to do well. Of course it is important to see your doctor regularly if you are seeing a statin drug.

tobokie: Any thoughts on niacin supplements and phitosteryles

Speaker_-_Dr__Nissen: Niacin should always be used under a doctor's supervision. Phytosterols are always added to foods such as margarine and can lower bad cholesterol by 6 - 10 %. They are often helpful for people with mild degrees of cholesterol elevation or to produce further reduction in LDL cholesterol in those who are on medication for cholesterol reduction. Two commonly used products are benecol and take control margarine.

tobokie: If statins are not well tolerated are their alternatives to reduce cholesterol in persons with plaques?

Speaker_-_Dr__Nissen: Yes. Although we always try to find one of the statins that a patient can tolerate. In most cases, a low dose of a statin can be administered without side effects. If a statin is absolutely not tolerated, a drug that inhibits absorption of cholesterol, known as ezetimibe (zetia) can be prescribed. But, ezetimibe has never been shown to reduce the risk of heart attack or stroke. Therefore, a statin is always preferred.

caddman11: Do you need to take the large doses of Niasan all at one time or can you take smaller doses several times a day to prevent flushing?

Speaker_-_Dr__Nissen: The major problem with Niacin is that it can produce intense flushing of the skin. This can be reduced by splitting up the dose of niacin during the day. Some patients also find that they have less flushing with a slow release form of niacin. There are several brands of slow release niacin but one popular brand is known as niaspan.

Terri: If people are unable to take statins to reduce cholesterol, would diet and exercise be enough to do so? Also would learning to control stress help?

Speaker_-_Dr__Nissen: For most people with elevated cholesterol, diet and exercise are helpful but they are not enough. Reducing stress can be helpful for heart disease patients but does not lower cholesterol levels.

danhamrick: Is the specific statin drug prescribed dependent on the patient's variables? Or is there a favorite among cardiologists at the Cleveland Clinic?

Speaker_-_Dr__Nissen: All statin drugs have been shown to be effective but they do differ in potency. We do not favor any specific statin although for patients that need larger reduction in choleterol, one of the more potent statins is more likely to be prescribed. All other things being equal, we prefer generic statins because they are less costly.

pszych_2: Would rosuvastatin then reduce LDL by 53.5% independent of what is eaten, or was diet a control?

Speaker_-_Dr__Nissen: In the ASTEROID study all patients were counseled on a healthy diet. There is no question that the combination of a prudent diet with a powerful statin is more effective than a statin alone.

Apo A-1 Milano

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wdbtexas: What is the status of the A-1 Milano drug being available to patients?

Speaker_-_Dr__Nissen: It is not currently available. Research has not progressed toward developing this as a therapy. There are still efforts underway but there are no studies currently planned.

Cleveland_Clinic_Host: Dr. Nissen, a lot of people are asking questions about the ApoA-1Milano study. Can you address this?

Speaker_-_Dr__Nissen: While promising, there are no current clinical studies in the world regarding Apo a1 Milano. When new studies are ready to enroll patients, they will be announced on this web site.

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Nissen is up. Dr. Nissen thank you again for taking the time to answer our questions today.

Speaker_-_Dr__Nissen: I have really enjoyed this opportunity to answer your questions. I hope the visitors have found this useful.

Cleveland_Clinic_Host: If you would like more information regarding cardiovascular disease prevention and treatment, please visit our web site at www.clevelandclinic.org/heart

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