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Dear Dr. Roach: Cholesterol numbers are not the whole story for stroke risk

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Dr. Keith Roach

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DEAR DR. ROACH: I am confused about overall risk for heart attack and stroke for my husband and I based on our cholesterol numbers and other risk factors. We are both in our 60s, never smoked, have normal blood pressure, nondiabetic and occasional drinkers. I am normal weight, eat well and exercise, but nevertheless, my total cholesterol creeps up each year. It is now 240. My husband is 60 pounds overweight and is sedentary with a poor diet. His total cholesterol is 159. He assumes he has a free pass based on his low cholesterol, and I assume I could be doomed despite my best efforts. What gives?

-- Anon.

A: Men and women have very different risks. Using some assumptions, I estimated both of your risks of having a heart attack or stroke in the next 10 years. For your husband, even without considering his weight and diet, his 10-year risk is 10.5%, while yours is 4.7%. Part of this difference is your protective HDL level of 77 you noted, but much of it is that women are at lower risk than men of the same age. Your husband's actual risk is probably substantially higher due to his sedentary lifestyle and poor diet, while yours may be even lower than the calculator estimates, due to eating well and exercising.

Although a statin drug would be expected to decrease your husband's 10-year risk by about 1.7%, I think that he could get additional benefit by improving his diet and starting an exercise regimen. Weight loss in absence of better diet and exercise has a very small impact on heart attack risk; it's probably more important for him to eat well and exercise, even if he doesn't lose a pound, than to eat poorly and lose weight.

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A normal total and LDL cholesterol is helpful, but there are many other risk factors. Almost 75% of people with a heart attack had cholesterol levels that, by themselves, appear low risk. It's critical to look at risk factors in the context of a whole person. He would do well to try to eat and exercise like his wife, but getting his doctor's OK to start an exercise plan is prudent.

A friendly reminder: There is no "free pass." A healthy diet and regular exercise help no matter your genes.

 DEAR DR. ROACH: I take 2.5 mg Eliquis twice daily. I also take 100 mg levothyroxine an hour or two before the Eliquis in the morning. During the day, I try to take vitamins. After dinner I take 20 mg Lasix, as I don't like running to the bathroom if I am not at home. At bedtime I take my Eliquis along with Cartia and metoprolol. How far from the time I take the meds and vitamins should I take the Lasix?

-- S.L.

A: I ran all your medications through a drug interaction checker and found no major issues. Both diltiazem (Cartia) and metoprolol can slow the heart rate, and the Cartia can slightly increase the blood level of the apixaban (Eliquis). Finally, very high doses (usually 80 mg or more) of furosemide can increase thyroxine levels of the blood. However, none of these is likely to cause problems, so you can take the medications at whatever time is convenient, as long as your doctor doesn't want you taking it at a particular time.

I would caution you about calcium, which can reduce absorption of thyroid medication.

Your pharmacist probably has a similar program to mine to check for interactions, but pharmacists have great expertise in medication interactions and are your first resource for asking questions like this.

         

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