Cholesterol lowering, nutrition and stroke prevention.

carotid stenosis 16,17 , were reduced by that approach from 12.6% to 3.7% of patients 15. More importantly, the two-year risk of stroke declined from 8.8% to 1%, and the two-year risk of myocardial infarction declined from 7.7% to 1% 15. There are some problems with high-dose statins, including aggravation of diabetes 18 , and myopathy. It is likely that both these problems are due to mitochondrial dysfunction due to depletion of CoQ10, and some evidence that supplementation with CoQ10 and L-carnitine (which is needed by mitochondria for fatty acid entry) may improve both problems 13. Another important approach is to use moderate doses of statin in combination with ezetimibe. This combination is synergistic; 10mg of atorvastatin or 5mg of rosuvastatin, when combined with 10mg of ezetimibe, lowers the LDL by as much as does 80mg of atorvastatin. The notion that ezetimibe may be harmful to the arteries was based on studies of intima-media thickness, which is not atherosclerosis 19. We found 20 that addition of ezetimibe regressed carotid plaque in patients with plaque progression despite statin therapy. However, it is crucial to recognize that " intensive medical therapy " does not just mean intensifying antiplatelet therapy or adding a statin. Smoking cessation, exercise, control of diabetes, control of blood pressure (preferably with an angiotensin converting inhibitor or angiotensin receptor blocker unless other therapy is indicated) and a Cretan Mediterranean diet are all important 21. Indeed when ranked in importance, smoking cessation and a Mediterranean diet (things that patients must do for themselves) are at or near the top. (It is for that reason that I wrote a book for the public 22). Perhaps the most underestimated is the importance of nutrition 23. A Cretan Mediterranean diet reduced stroke and myocardial infarction by over 60%, compared to a low-fat diet that was equivalent to the NCEP Step 1 diet 24. It is also the best diet for diabetics 25. That diet is high in beneficial oils such as olive and canola, high in whole grains, fruits, vegetables, lentils, beans and nuts, and low in saturated fats, trans fats and cholesterol. For North Americans to reduce their intake of animal flesh to the quantities consumed in the Cretan diet, it is probably easier to eat about four ounces of animal flesh every other day 22,23 ; fish should be favoured. A single large egg yolk contains ~237mg of cholesterol, more than …