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Cholesterol & chiropractic.rtf
Cholesterol, Chiropractic and Cardiovascular Health
Chiropractors are developing an interest in cholesterol levels, medications, and vascularissues since in the past there have been implications of a relationship between cervicalmanipulations and cerebrovascular arterial (CVA) events . Apparently current researchhas found that the purported relationship to be so rare that any factors associated withchiropractic manipulation and CVA events are more coincidental than causal [2-4].
Therefore the chiropractic profession has been focusing on how to be aware of a CVAevent in progress and how to prevent such an occurrence, leads to the need to understandthe importance of the current relationship between cholesterol levels and vascular events.
In one study that analyzed 61 prospective observational studies they failed to find anyassociation of total cholesterol (TC) with stroke mortality. Ultimately the total cholesterol(TC)/HDL cholesterol ratio was found to be more predictive of ischemic heart disease(IHD) mortality than total or non-HDL cholesterol. They also found a positive relationbetween cholesterol and stroke only in middle age and only in those with below-averageblood pressure (BP); at older ages (70-89), and particularly for those with systolic BPgreater than 145 mm Hg, total cholesterol was negatively related to hemorrhagic and totalstroke mortality [5,6].
In the Ezetimibe (Zetia) and Simvastatin (Zocor) in Hypercholesterolemia EnhancesAtherosclerosis Regression (ENHANCE) study they found in their trial that patients whohad an LDL cholesterol level of 178 mg per deciliter (4.60 mmol per liter) whilereceiving combination therapy with simvastatin plus ezetimibe, the carotid intima-mediathickness progressed by 0.0111 mm. With a similar level of LDL cholesterol (167 mg perdeciliter [4.32 mmol per liter]) during therapy with 80 mg of atorvastatin (Lipitor) in theASAP study, intima-media thickness regressed substantially, by 0.031 mm .
However it has been questioned, "Does the ENHANCE study prove that ezetimibeprovides no benefit when added to statin therapy or, for that matter, as monotherapy? Fornow, the study's findings are a red flag but not a black box ."
"The results of ongoing trials, such as the Improved Reduction of Outcomes: VytorinEfficacy International Trial [IMPROVE-IT]), which will not be available until at least2011, are expected not only to help define the role of ezetimibe in the treatment ofhypercholesterolemia but also to provide insight into the biology of LDL cholesterollowering and the use of carotid intima-media thickness as a surrogate indicator ofcoronary events .
"Until such data are available, it seems prudent to encourage patients whose LDLcholesterol levels remain elevated despite treatment with an optimal dose of a statin toredouble their efforts at dietary control and regular exercise. Niacin, fibrates, and resinsshould be considered when diet, exercise, and a statin have failed to achieve the target,with ezetimibe reserved for patients who cannot tolerate these agents ."
The direction of vascular health and prevention seems to be towards issues of vascularinflammation and TC/HDL ratios  and not so much on lowering total cholesterollevels. Therefore some markers such as homocysteine [10-12], c-reactive protein [13,14]and clinical indicators of precursors of vascular inflammatory processes  may offer awindow into a patient's potential cardiovascular health. There is even some suggestionthat the positive affects of statin medications are associated with their ability to reducevascular inflammation processes  and not related to their affect on cholesterol. So farthat leaves us best with interventions that offer low risk such as exercise [17,18], lowinflammatory diets , and increasing omega three supplementation  all of whichwould seem to be the recommended first line in treatment and prevention of possiblevascular events.
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2. Thiel HW, Bolton JE, Docherty S, Portlock JC. Safety of Chiropractic Manipulation ofthe Cervical Spine: A Prospective National Survey. Spine. 32(21):2375-2378, October 1,2007.
3. Rubinstein SM, Leboeuf-Yde C, Knol DL, de Koekkoek TE, Pfeifle CE, van TulderMW. The Benefits Outweigh the Risks for Patients Undergoing Chiropractic Care forNeck Pain: A Prospective, Multicenter, Cohort Study. J Manip PhysiologicalTherapeutics. Jul 2007;30(6): 408-18.
4. Cassidy JD, Boyle E, Côté P, He Y, Hogg- Johnson S, Silver FL, Bondy SJ. Risk ofvertebrobasilar stroke and chiropractic care: results of a population-based case-controland case-crossover study. Spine. 2008 Feb 15;33(4 Suppl):S176-83.
5. Prospective Studies Collaboration. Blood cholesterol and vascular mortality by age,sex and blood pressure: a meta-analysis of individual data from 61 prospective studieswith 55 000 vascular deaths. Lancet. 2007;370:1829-1839.
6. Amarenco P, Steg PG. The paradox of cholesterol and stroke. Lancet. 2007;370:1803-1804.
7. Kastelein JJ, Akdim F, Stroes ES, Zwinderman AH, Bots ML, Stalenhoef AF, VisserenFL, Sijbrands EJ, Trip MD, Stein EA, Gaudet D, Duivenvoorden R, Veltri EP, MaraisAD, de Groot E; the ENHANCE Investigators.Simvastatin with or without Ezetimibe inFamilial Hypercholesterolemia. N Engl J Med 2008;358:1431-a-1443.
8. Brown BG, Taylor AJ. Does ENHANCE Diminish Confidence in Lowering LDL or inEzetimibe? N Engl J Med. 2008 Mar 30.
9. Drazen JM, Jarcho JA, Morrissey S, Curfman GD, Cholesterol Lowering andEzetimibe. N Engl J Med; March 30, 2008.
10. Cui R, Moriyama Y, Koike KA, Date C, Kikuchi S, Tamakoshi A, Iso H; JACCStudy group. Serum total homocysteine concentrations and risk of mortality from strokeand coronary heart disease in Japanese: The JACC study. Atherosclerosis. 2007 Dec 27;
11. Vanuzzo D, Pilotto L, Lombardi R, Lazzerini G, Carluccio M, Diviacco S,Quadrifoglio F, Danek G, Gregori D, Fioretti P, Cattaneo M, De Caterina R. Bothvitamin B6 and total homocysteine plasma levels predict long-term atherothromboticevents in healthy subjects. Eur Heart J. 2007 Feb;28(4):484-91.
12. Tanne D, Haim M, Goldbourt U, Boyko V, Doolman R, Adler Y, Brunner D, BeharS, Sela BA. Prospective study of serum homocysteine and risk of ischemic stroke amongpatients with preexisting coronary heart disease. Stroke. 2003 Mar;34(3):632- 6.
13. Tanne D, Benderly M, Goldbourt U, Haim M, Tenenbaum A, Fisman EZ, Matas Z,Adler Y, Zimmlichman R, Behar S, C- Reactive Protein as a Predictor of IncidentIschemic Stroke Among Patients With Preexisting. Cardiovascular Disease. Stroke. 2006Jul;37(7):1720-4.
14. Cao JJ, Thach C, Manolio TA, Psaty BM, Kuller LH, Chaves PH, Polak JF, Sutton-Tyrrell K, Herrington DM, Price TR, Cushman M. C-reactive protein, carotid intima-media thickness, and incidence of ischemic stroke in the elderly: the CardiovascularHealth Study. Circulation. 2003 Jul 15;108(2):166-70.
15. O'Callaghan PA, Fitzgerald A, Fogarty J, Gaffney P, Hanbidge M, Boran G, EnrightH, Murphy J, McCarthy B, Graham IM. New and old cardiovascular risk factors: C-reactive protein, homocysteine, cysteine and von Willebrand factor increase risk,especially in smokers. Eur J Cardiovasc Prev Rehabil. 2005 Dec;12(6):542-7.
16. Shishehbor MH, Brennan ML, Aviles RJ, Fu X, Penn MS, Sprecher DL, Hazen SL.
Statins promote potent systemic antioxidant effects through specific inflammatorypathways.Circulation. 2003 Jul 29;108(4):426-31.
17. Kodama S, Tanaka S, Saito K, Shu M, Sone Y, Onitake F, Suzuki E, Shimano H,Yamamoto S, Kondo K, Ohashi Y, Yamada N, Sone H. Effect of aerobic exercisetraining on serum levels of high- density lipoprotein cholesterol: a meta-analysis. ArchIntern Med. 2007 May 28;167(10):999-1008.
18. Halverstadt A, Phares DA, Wilund KR, Goldberg AP, Hagberg JM. Enduranceexercise training raises high-density lipoprotein cholesterol and lowers small low-density
lipoprotein and very low- density lipoprotein independent of body fat phenotypes in oldermen and women. Metabolism. 2007 Apr;56(4):444-50.
19. Seaman DR. The Diet-Induced Proinflammatory State: A Cause of Chronic Pain andOther Degenerative Diseases? J Manipulative Physiol Ther 2002; 25:168-79.
20. Calabresi L, Villa B, Canavesi M, Sirtori CR, James RW, Bernini F, Franceschini G.
An omega-3 polyunsaturated fatty acid concentrate increases plasma high-densitylipoprotein 2 cholesterol and paraoxonase levels in patients with familial combinedhyperlipidemia. Metabolism. 2004 Feb;53(2):153- 8.
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