To Your Good Health: Patient concerned that statins increase the risk of dementia

Keith Roach, M.D., syndicated columnist

DEAR DR. ROACH: I am a 74-year-old female who is 5 feet, 3 inches tall, and weighs 120 pounds. I live a healthy, active lifestyle. At age 59, during a regular doctor appointment, I was told that I had unknowingly had a heart attack. I had an angiogram, which showed no blockages. I was also given a nuclear imaging test to ascertain if there were any blockages in the smaller arteries to the heart. There were none. It was several weeks before I was cleared to resume physical exercise.

It was determined that I had suffered a coronary spasm (variant angina) that had induced the infarction. I saw a cardiologist for a few years, but I have had no issues or problems since. My doctors have prescribed 40 mg of atorvastatin daily for the past 15 years. My cholesterol is consistently about 180 mg/dL, with my HDL cholesterol near 75 mg/dL and my LDL near 90 mg/dL.

I have heard there is some evidence that statins can adversely affect dementia. What are your thoughts? — K.S.C.

ANSWER: Vasospastic angina, also called variant angina, is a cause of chest pain in both women and men due to low blood flow when the blood vessels to the heart constrict. Heart attacks often happen in combination with blockages in the arteries to the heart, but they can occur with no blockages at all.

The diagnosis is made when a spasm is seen during an angiogram in a person with angina and changes in their electrocardiogram. Management includes medication to prevent vasospasm, such as nitroglycerine and calcium blockers, as well as smoking cessation, if appropriate.

Statin drugs like atorvastatin have been proven to help prevent a coronary spasm, so it does help prevent symptoms (and another heart attack). It would be best for you to keep taking it, but I understand why you would be concerned if it really did increase the risk of dementia.

The relationship of statins and dementia can be confusing. Of the most common two types of dementia, vascular dementia and Alzheimer’s, statins play a clear role with the first, since they are indicated in people who have strokes with or without dementia as a result of the stroke, and they possibly play a helpful role with the second. Large studies have shown that people taking statins have a reduced risk of Alzheimer’s, although controlled trials have not confirmed this. Still, the empiric data shows significantly reduced dementia among statin users.

On the other hand, some people taking certain statins may have memory effects as a result of the statin. Although memory loss is not a common side effect, when it is reported, it’s almost always with “lipophilic” statins like atorvastatin and simvastatin. It’s almost never with “hydrophilic” statins like pravastatin and rosuvastatin. I tend to prescribe rosuvastatin preferentially because of this concern with new patients, but I do not change my patients who are doing well on atorvastatin.

So, while statins reduce overall dementia due to their beneficial effects on blood vessels, some people may experience memory loss with certain statins, which seems to be reversible by changing to a different statin. In a person with a clear indication for a statin, such as a person with a vasospastic angina, the benefits are very likely to outweigh the harms.

DEAR DOCTOR ROACH: I have recently learned that my sibling, age 70, has rare cancer of the thymus. She will be getting chemotherapy and perhaps radiation treatment. I have heard of immunotherapy. Is this an option?

Would you know what could have caused this type of cancer? When she was younger, she had bouts of rosacea; could there be a connection? — A.H.

ANSWER: The thymus is a gland in the upper chest that is critical for the development of the immune system during early childhood. Tumors of the thymus are rare, and thymic cancer is rarer still. There are no known risk factors for thymic cancer, and rosacea isn’t one to expect.

If the cancer has not spread outside of the thymus, surgery can be curative, but people with high-risk cancers (by pathological evaluation) are usually recommended to follow surgery with radiation treatment. If the cancer has spread, then chemotherapy is the first-line treatment. Some people are cured by chemotherapy, even with advanced disease. Unfortunately, people with thymic cancer are at a very high risk for serious immune-related side effects from immunotherapy, so this therapy is not helpful in people with thymic cancer.

Because this is such a rare cancer, the optimum treatment isn’t known. I wish her the best in her treatment.

DEAR DR. ROACH: My 31-year-old daughter is pregnant with her first baby. She is in her fifth month, and the doctor has told her that her baby is at the 75th percentile in growth. Can you please advise if this is a concern? — O.G.S.

ANSWER: The 50th percentile is, by definition, an average-sized baby (for the appropriate population). The 75th percentile makes her baby a bit bigger than average but, by no means, abnormally large. We start to worry when the baby is above the 90th percentile, although the 95th and 97.75th percentile are commonly used by researchers to define “macrosomia” — a baby who is larger than expected.

When a fetus is that large, there are risks to the mother, including protracted labor, the need for a caesarean birth, and damage to the genital tract and uterus. Risks of a very large baby also include damage to the shoulder during delivery. When a baby is that big, there is a concern that the mother may have high levels of insulin, which acts as a growth hormone for the baby.

Moms who gain excess weight during pregnancy are at a higher risk for larger babies. There are other rare causes. All expectant mothers are screened for the form of diabetes that is associated with pregnancy. A baby born to a mom with diabetes is at risk for low blood sugar when they’re first born.

However, your grandchild is not in a range where any of these bad outcomes are likely. If your daughter or the baby’s father is a large person, there is simply a higher chance that they’ll have a large baby.

On the other side, a developing fetus that is less than the 10th percentile (but especially less than the 3rd percentile) for weight is a bigger concern because there are many worrisome causes for the baby not to grow. Her baby seems to be in a very healthy range.

Finally, the ultrasound pictures aren’t perfect and can under- or overestimate fetal size, so I really wouldn’t get too concerned.

EDITOR’S NOTE: Readers may email questions to ToYourGoodHealth@med.cornell.edu or request an order form of available health newsletters or mail questions to P.O. Box 536475, Orlando, FL 32853-6475.


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