By Richard Ellin, MD, FACP
Question: I am 40 years old. For the last 3 years I have participated at local races in my age group. I now train 6-10 hours weekly, and my diet is not perfect but not too bad. At my last checkup my blood test results were: cholesterol, 279, HDL, 54 and LDL, 210. My blood pressure was also high. And an echocardiogram showed a “less than 30% diameter stenosis” in one of my carotid arteries. I asked my cardiologist if I could anything to improve the cholesterol and blood pressure issues but he said given my lifestyle, nothing will change even if I turn vegetarian. (Damned genes). So he prescribed me a daily dose of 10mg Olartan (olmesartan medoxomil) and 10mg Crestor (rosuvastatin). My blood test and pressure results were perfect one month after that. Another issue is that I have an unusually high max heart rate for my age, I regularly go over 190.
My questions are:
1. Is it safe for me to push myself like that?
2. If the answer is yes, are those medicines, or my “condition,” affecting my performance? — Michalis C.
Dr. Richard Ellin Responds: There are several issues in your questions, Michalis. Let me take them one at a time.
First, regarding your cholesterol numbers, there is no question that your total cholesterol of 279 and LDL of 210 are very high. (Optimal total cholesterol is <200, and LDL <130). However, you have a healthy HDL of 54. The relevance of the cholesterol numbers is that it places you at higher risk for cardiovascular disease (plaque buildup and clot formation in the arteries, mainly to the heart muscle and brain).
Just how much this risk is increased is a matter of debate. Certainly, with the added risk factor of hypertension (although of a mild degree, based on the numbers you gave), the concern regarding the high cholesterol numbers is more serious. I presume, by your omission, that you don’t have the other major cardiovascular risk factors (smoking, diabetes, or strong family history).
Many physicians, including myself, use some form of a risk calculator to figure an individual’s specific risk. This helps to stratify people into low risk, intermediate risk, and high risk, rather than just making our own best guess. Perhaps the most commonly used such risk calculator is based on the Framingham study, one of the largest and longest-running studies of cardiovascular disease ever undertaken.
The National Cholesterol Education Program has adopted a 10-Year CVD Risk Calculator as its official method of risk stratification.
Using this calculation tool, your risk of developing cardiovascular disease in the next 10 years is 5%, assuming an average systolic BP of 134, and using the fact that you are already on BP medication. Anything less than 10% is considered low risk. However, with medication to lower both the BP and cholesterol, your risk is much lower. For example, if the Crestor gets your total cholesterol down to 190 (and perhaps it will get it lower), and your BP averages 10 points lower at 124, your risk drops to 1%.
It is important to realize that 5% or 1% are both low risks. The question is really not whether you need medication to lower your risk from 5% to 1%. The question is whether being on medication for cholesterol and BP today lowers your risk when you are 60, 70, or 80 years old. Unfortunately, we don’t know the answer to that, but I think most doctors would say that it likely does lower that risk.
In addition, you have evidence that there is already a plaque in your carotid artery. 30% is insignificant and will cause no symptoms nor increased risk now, but it is a signal that, for whatever reason, your body is laying down plaque in a major artery. Therefore, based on not only your risk factors, but also on the known presence of carotid plaque, I think your doctor is doing the right thing in recommending that you be on BP and cholesterol medication. Some physicians would also advise you to take an aspirin a day, but that is a topic for another discussion.
That is a very long answer to one aspect of your inquiry, but it is so important for so many people that it’s worth understanding well. Now, let me address the other questions you raised.
Regarding your maximum heart rate, there should be no danger in attaining a heart rate during exercise of 180-190. For training purposes, you don’t need to get it that high, but it’s not an issue if it happens to get that high.
Provided that one has a healthy heart, there is no danger in attaining heart rates in this range, or higher. The risk of attaining higher heart rates is proportional to how healthy the heart is. Only if you have your heart thoroughly checked out by a physician, and it’s found to be in excellent health, would attaining a much higher heart rate be safe.
Regarding your medicines, neither should limit your exercise tolerance or endurance. And neither would limit your heart rate. However, Crestor is a statin, and all statins carry a small, but real, risk of causing muscle injury. If you should experience anything more than the usual aches after working out, let your doctor know.
One final note: For those cyclists at any age whose 10-year Framingham risk score is in the intermediate range (10-20%), we sometimes recommend a coronary CT scan, which can help further stratify one’s risk, thereby allowing their physician to make a better judgment about how important risk-reduction is. One can obtain such a scan for about $125 (based on the Atlanta market). Since it is an X-Ray test, it does involve a small amount of radiation but only needs to be done once every several years, at most. Its use is somewhat controversial, but many doctors find the information gleaned from it useful in deciding whether or not one needs medication in order to achieve risk-factor reduction.
Richard Ellin, MD, FACP, is a board-certified specialist in Internal Medicine who practices in Alpharetta, Georgia. He received his medical degree and completed residency at Emory University, and has been in practice with Kaiser Permanente for 26 years. He is also an avid cyclist.