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A patient’s hard questions about his easy answer

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Special to The Times

She was in good health, rode horses regularly and, as an articulate attorney, was not one to simply accept my medical advice without explanation. She came in for yearly checkups, and we had developed a good rapport during the last 10 years.

Our main discussion concerned her cholesterol level: It generally ranged between 230 and 260, with a “bad” cholesterol (low-density lipoprotein) measurement of between 140 and 160.

The official recommendations for lipids are often changing, although the American Heart Assn. guidelines have consistently indicated that a total cholesterol under 200 is desirable. Current AHA recommendations for LDL cholesterol are:

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Less than 100 mg/dL -- optimal; 100 to 129 mg/dL -- near optimal; 130 to 159 mg/dL -- borderline high; 160 to 189 mg/dL -- high; 190 mg/dL and above -- very high. Many practicing cardiologists and lipid experts say these target numbers are far too high, and shoot for LDL cholesterols of 70 or 80 even in patients who lack known heart disease.

My patient was in the “borderline high” category, and she was reluctant to take cholesterol-lowering medication. She viewed herself as healthy, and medication might alter that self-image.

After all, she had no heart disease, no family history of heart disease and no significant risk factors for heart disease. She didn’t smoke, had normal blood pressure and wasn’t overweight.

I, on the other hand, was not nearly as comfortable as she was with her high cholesterol numbers. I suggested Lipitor or other statin drugs every time she came to see me. She accepted this discussion as her doctor doing his job, but continued to resist my prescriptions.

And though the medical literature had recently shown Lipitor to have dramatic effects on the coronary arteries, preventing the progression of “angry” plaque, there was still no direct evidence that it prevented heart disease. Many physicians believe this to be the case, but we lack proof of it.

So the discussion went -- from visit to visit -- and we remained at loggerheads. She continued to insist that her diet was optimal, consisting of practically all vegetables, with little dairy and no desserts. Finally, on a recent visit, her total cholesterol rose to 265, and her anti-pill resolve appeared to weaken.

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“Don’t these drugs have significant side effects?” she asked weakly.

“I’m on them myself,” I replied. “And I tolerate them fine.” I told her that some people feel a muscle twinge or some stomach upset, but many feel nothing. I would monitor her liver and muscle enzymes, but they would most likely be fine.

“Why doesn’t that reassure me?” she asked dryly.

Suddenly I had another idea.

I suggested a high-speed CT scan of the chest for calcium scoring, evidence of calcified coronary plaques. I would also order an ultrasound of her carotid arteries (in the neck), which would provide easy evidence of the kind of plaques that correlate with plaques in the coronary arteries of the heart.

Neither of these tests is perfect, but can provide further rationale for starting a statin drug if either reveals diseased arteries.

She was so delighted with these suggestions that I chided myself for not thinking of them earlier. I acknowledged that I had a clinical instinct against performing tests on people who were completely healthy, and that many of my patients had the same instinct.

But tests are often the most helpful before an illness fully blossoms, when preventive measures such as diet alteration, exercise and, if necessary, medications can help patients maintain their health.

Finally, we were working together -- in the gray area of healthcare where there is no right or wrong answer. We had made a joint decision that was far more gratifying to both of us than a unilateral one, as occurs when a patient stubbornly refuses a treatment that a doctor is stubbornly insisting on.

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Beyond the many nuances unique to a fully functioning doctor-patient relationship, there is also the essential question of how quickly to use a medication. I am still learning how to avoid the knee-jerk prescription, because many pills, including statins, are long-term projects.

Once a patient becomes committed to them, all other goals become blurred. It is too easy for a medicine-taker to forego important lifestyle changes.

I know this from my personal experience as well as that of my patients. Once on a cholesterol-lowering drug, it is too easy to revert to a lax diet. I call this the “hot fudge sundae with Lipitor on top” phenomenon.

In this patient’s case, the tests were negative, with no calcifications in the heart and no significant plaques in the arteries of the neck.

Now we both felt more comfortable with the decision not to treat her with a medication, at least for now.

And we were both comfortable with the fact that she had a healthy lifestyle -- and was viewing pills as the last, rather than the first, resort.

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Dr. Marc Siegel is an internist and an associate professor of medicine at New York University’s School of Medicine. He is also the author of “False Alarm: The Truth About the Epidemic of Fear” and “Bird Flu: Everything You Need to Know About the Next Pandemic.”

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