Are we focusing too much on cholesterol’s dangers? Have we missed a key to heart disease prevention?

For years the thinking has been that ‘bad’ LDL cholesterol gets into the artery wall, where a clot can form, eventually blocking it, causing heart attacks and stroke. Up to 8 million Britons currently take cholesterol-lowering statins.

However, major clinical trials have been launched to determine the role of inflammation in heart disease. This is something that not many people know about. 

If you are suffering from heart disease, you may be given a stronger anti-inflammatory medication to help you.

A recent study at the Montreal Heart Institute in Canada found that when patients were given colchicine — an anti-inflammatory drug long used to treat gout — within a few days of a heart attack, they were less likely to have another heart attack than patients given a placebo.

Major trials are now under way to test the part inflammation plays in heart disease, though this is not a risk that many people are aware of [File photo]

While major clinical trials are underway to examine the impact of inflammation on heart disease, it is not something that most people know about. [File photo]

Since long has the idea of inflammation causing heart disease been known. Nearly 30,000 women who were otherwise healthy had their cholesterol levels and C-reactive proteins (CRP) measured. This was done in 1997 and again eighteen years later.

The study concluded that women who had higher levels of inflammation were more likely than their counterparts with lower cholesterol to develop a heart condition.

Ten years later, study leader Paul Ridker, a cardiologist at Brigham and Women’s Hospital in Boston and a professor of medicine at Harvard University, ran a much bigger trial called JUPITER, giving people with high CRP but low cholesterol a statin or placebo. The statin group had 44% less chance of suffering a cardiovascular event such as heart attacks than those who received it.

But the study didn’t clarify whether lowering cholesterol or inflammation was more important because statins do both.

Trials of diabetics, who have been shown to be at high risk for developing heart disease, provide further evidence.

What is perplexing is that while high blood sugar levels drive the risk of heart attack, ‘only treating blood glucose does not reduce that risk’, says Professor Robin Choudhury, a cardiologist at Oxford University and an authority on inflammation.

Also, there is something else going on. Professor Choudhury’s team aims to transform the way people think of diabetes.

‘The goal is to identify opportunities to provide new treatment options to reduce the burden of heart disease,’ he says.

Another idea is that inflammation plays a key role, and high levels of glucose in diabetes stimulate immune cells.

Separately, it is thought that cholesterol’s role in heart disease isn’t just about blocking arteries: it, too, is involved in raising inflammation. ‘Bad’ cholesterol in the wall of the artery forms the plaques that lead to the clots or blockages — but the new thinking is that it plays a much more active chemical role that involves inflammation.

‘We now know that if you lower cholesterol, markers of inflammation come down as well,’ says Professor Choudhury.

‘The problem starts because cholesterol shouldn’t be in the artery walls. There is a process for removing it but if that doesn’t work, then the immune system gets called in.’

This triggers molecules known as interleukins that draw in immune system troops, ‘and the scene is set for inflammation to damage the heart’, he explains.

It makes sense to use statins and drugs to reduce inflammation.

However, researchers such as Professor Choudhury have found that it’s no good using any old anti-inflammatory. ‘You need ones that target the interleukins involved,’ he says.

In 2019, Professor Ridker conducted a study with 4,500 patients suffering from type 2 diabetes and heart disease. The trial was funded by the National Heart, Lung and Blood Institute of the U.S. Methotrexate was given to patients as an anti-inflammatory drug. This was done in order to reduce the number of heart attacks and deaths. It didn’t. The reason, it turned out, was that it didn’t affect the relevant interleukins, specifically IL-1 -beta and IL-6.

However, the anti-inflammatory drug colchicine, which has been used for 100 years, does target these — and according to Nature magazine, some cardiologists have begun prescribing it.

Although large-scale clinical trials have shown that suppressing inflammation can lower the risk of heart disease, it is not clear if these drugs are appropriate for prevention.

These medications could prove to be very beneficial for patients who have been taking them for many years. There are potential side effects that range from nausea and vomiting, liver problems and even lung disease.

Ziad Mallat is a Professor of Cardiovascular Medicine at the University of Cambridge. ‘The risk is that the patient becomes more vulnerable to infections,’ he says. These anti-inflammatory medications lower the effectiveness of your immune system.

‘Colchicine does lower inflammation affecting the heart but patients have more infections,’ says Professor Mallat, who has recently published research on a drug called Aldesleukin that can both bring down inflammation and keep the protective side of the immune system working.

He and his colleagues are now looking into the possibility of creating an mRNA vaccine that is similar to Covid-19. This vaccine would identify the protein responsible for the cholesterol-driven inflammation, and block it.

But is the new approach the right way round — does the heart disease actually come first, then the inflammation?

That’s the suggestion from a senior cardiovascular research scientist, Dr James DiNicolantonio of Saint Luke’s Mid America Heart Institute in the U.S.

‘Rather than being the cause of heart disease, inflammation is the body’s response to poor diet, lifestyle and environmental factors,’ he says. ‘We should be aiming for optimum amounts of micronutrients: deficiencies of vitamins and minerals are key factors in heart disease, as is a diet high in refined carbohydrates and sugar.’

But Professor Ridker doesn’t believe we have to choose one or the other. It’s quite the opposite.

‘The likes of diet, exercise and smoking cessation not only all lower systemic inflammation, they also reduce cardiovascular event rates,’ he told Good Health. 

‘So nutrition and lifestyle factors matter more than ever for prevention.’

The microscope

The health quiz was answered by Sir Roy Strong, an 85-year-old art historian. 

Do you have the strength to climb up those stairs?

I’m up and down the stairs all day, but I wouldn’t run. Each morning, I exercise for between 10 and 20 minutes. I also visit the gym twice per week. 

Jonty was the first person I met. [his personal trainer Jonathan Williams]Nine years ago, he attempted to show me how to bike. But what we didn’t know was at the age of 77 you cannot learn balance. Then he arrived one day with a tricycle — and I still use it.

Art historian Sir Roy Strong, 85, answers our health quiz

The health quiz was answered by Sir Roy Strong, an 85-year-old art historian.

How about five for a daily breakfast?

Jonty’s very keen on vegetables such as broccoli, cabbage, cauliflower — I love a good dish of roasted vegetables.

Ever dieted?

The 1970s were a rough time for me. At the age of 31, I became a museum administrator. It is a great way to be exposed to grand things. Being extremely vain I went on a difficult diet. Jonty has now got rid of the fat at the side and the back — he’s got my pectoral muscles from 38in to 43in — but I’ve still got a band of fat round my middle. My 32in waist would be ideal, but it’ll have to shrink to 34in.

Are there vices?

Before my dinner at 6, I will have a Gin and Tonic at 5.30pm.

Do you have any relatives with health issues?

My mom lived till the age of 89, my dad until the age 90. They did nothing to make it possible so maybe there was a bit of luck.

Worst illness?

When I was in my early teens, I was told I had a hole in my heart and wouldn’t live a year. My birthday in 2019 was marked with a blackout. When I went to the refrigerator for some milk, the next thing I remembered was that I was looking up at the bloody pool on the ground. A pacemaker was needed to correct my hearing loss in my left ear.

Take any pill?

Additional information about heart rhythmmaker and high blood pressure is available in Abour 6.

Are you looking for alternative methods?

They are rather boring. You can get cod liver oil and vitamin D.

Ever been depressed?

Feeling low can be a little different. My wife and I were a couple. [Julia]My mother died in 2003. I moved to Ledbury because my love for creating was what gave me the lift.

How to get rid of hangovers

I’ve been drunk once, in about 1956, and I remember thinking ‘never again’.

How do you stay awake at night?

Although I listen to the radio all day, it is hard for me to sleep. I do occasionally catch the World Service.

Any phobias?

I don’t like snakes. I love cats — I couldn’t live without a cat. Tabitha lies on my four-poster canopy.

Would you like to live forever?

What’s the point?

Types And Shadows; The Roy Strong Diaries, 2004-2015 is now out in paperback (£14.99).