Thousands of Scots will benefit from a new treatment for high cholesterol amid fresh warnings dietary changes are ‘not always enough’ to prevent heart disease, even in younger people.
The Scottish Medicines Consortium (SMC) has approved a cholesterol-lowering drug for patients who are unable to tolerate statins and are at increased risk of heart attack or stroke.
One of the most common side effects of statins is muscle pain which can range from mild to severe and affects up to 10% of patients. Around 8,500 Scottish patients will benefit from the new treatment - Nustendi - which works by reducing levels of ‘bad cholesterol’ known as high-density lipoprotein (LDL).
Heart disease was the leading cause of death in Scotland in 2020, equating to nearly 50 people every day.
High cholesterol is often referred to as a hidden risk factor because there are no typical signs or symptoms, which means regular testing is vital. Some people may also be genetically predisposed to it.
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Professor Adrian Brady, a Consultant Cardiologist at Glasgow Royal Infirmary, says anyone with a family history of heart disease should get their levels checked and should also ask for a more detailed test, known as a lipid profile.
Normally patients are given a cholesterol total with 5 mmol/L or less considered optimal.
A lipid profile gives a more detailed risk profile showing levels of good and bad cholesterol (LDL and HDL) and Triglycerides - the most common type of fat in the body.
Prof Brady said he was currently treating a number of heart attack patients in their thirties and forties with statins.
He said: “Anyone with a family history of coronary heart disease - either a grandparent or parent - should get their cholesterol checked and they should ask for a lipid profile.
“Strictly speaking, to identify cardiovascular risk you need to do a cholesterol profile where you see the different sub-fractions of cholesterol and not just the total figure.
“GPs might not like that but it’s the truth.
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"One of the sub-fractions, HDL, is protective. For actual risk stratification you need the ratio of good guys to bad guys.
“Diet and exercise are fundatmental and may make a difference but it may not be enough for some people.”
The new treatment combines two existing drugs, ezetimibe and bempedoic acid, which was approved separately earlier this year and is the first oral cholesterol-lowering treatment in more than 18 years.
Experts say the use of multiple medicines can lead to reduced adherence to treatment and increased morbidity.
“Stains are life-saving wonder drugs but there are a portion of patients who do have statin intolerance," said Prof Brady, who is Honorary Professor of Cardiology at the University of Glasgow.
"It’s a small number but for those people the options are more limited.
“This is a new drug which acts on a slightly different pathway (to statins) but has a similar effect in reducing the amount of cholesterol that the liver makes.
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“Statins affect enzyme systems not just in the liver but in the muscles and in all sorts of places. This drug works in the liver and doesn’t affect the muscles so you don’t get the muscle side effects like leg cramps and pains which affects between five and 10% of patients.
“So for those individuals it may be a very valuable drug. Does it have the evidence base of statins? No it doesn’t but it does lower cholesterol and I’m sure it will be of use in Scottish patients.”
There are an estimated 700,000 people living with heart and circulatory diseases in Scotland and just over a quarter of related deaths are associated with high LDL cholesterol.
Doctors use a cardiovascular risk score developed in Dundee University in 2006 to identify those who are most likely to develop it over the next ten years.
Those with a score of 20 or more are generally advised to take cholesterol lowering medication.
Prof Brady said it is quite difficult to reduce high cholesterol through diet alone and said the main culprits are fats found in meats including pork, lamb, bacon and mince.
He said: “What we know, is that we in the West of Scotland have quite high cholesterol and are prone to coronary heart disease.
“You should have a diet that is rich in oats, which lower your cholesterol and your blood pressure.
”Stopping smoking is more effective than any other intervention. It’s mostly our genetics. Diet and exercise are the cornerstones but they may not be enough.”
Prof Brady was involved in setting up Football Fans in Training, a nationally funded health programme run by football clubs in Scotland that provides health checks for supporters including cholesterol testing.
He said: “Scotland leads the world in that. Seventy-five clubs in England were due to start before Covid happened. It’s now also being used in the Netherlands.”
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