A Pandemic Disease that Should Really Scare You!

Somewhere lurking out there, there is a virus that can suddenly put you into a coma. When you awaken, if you ever do awaken, you may be surprised to find that you have Parkinson’s disease, even if you’re in the prime of your life, a movement disorder that can accurately be described as a healthy mind that is trapped in a prison of a body. This disease is called encephalitis lethargica and no one really knows for sure what causes it, much less how to cure it, although an undiscovered virus is the likely culprit. Striking in 1917, encephalitis lethargica caused an epidemic that lasted for a decade before suddenly disappearing as mysteriously as it had arrived. But not before leaving a wake of incapacitated victims in its wake. And all of this raises the question, why the hell haven’t you ever heard of this horrible disease? The answer is pandemic influenza, a disease that was far worse than encephalitis lethargica by many orders of magnitude.


“Awakenings” is based on the work of neurologist Oliver Sacks with patients with encephalitis lethargica in the 1960’s in a long term care facility (yeah, 45 years after most of them contracted the disease). The film stars Robin Williams and Robert DeNiro.

A YouTube video clip of a Diane Sawyer interview with Oliver Sacks with images of encephalitis lethargica patients. The quality isn’t the greatest due to degradation of the original film, but it is still very much worth your time to watch it. Encephalitis lethargica isn’t completely a thing of the past. There still are sporadic cases that pop up from time to time.

There are two main types of influenza that infect humans, influenza A and influenza B. In 1918 a particularly nasty strain of influenza A called H1N1, aka: Spanish Flu, killed between 50-100 million people worldwide. To put that into perspective, all deaths (military and civilian, including the Holocaust) in World War II, the bloodiest war in history, only totaled about 50 million. And World War II lasted from 1939-1945, six years compared to the two measly years (1918-1919) that Spanish Flu was in circulation. To make matters worse, Spanish Flu was particularly deadly to young adults, mowing down many of the healthiest and most productive citizens with its bloody reaper.


The makeshift influenza wards at Fort Riley, Kansas during the 1918 influenza pandemic.

One hypothesis for the increased mortality in what is generally the healthiest cohort of people, people who are in their prime, is based on the fact that only a small portion of the damage from influenza is actually caused by the virus itself. The inflammatory response of the body to the influenza virus is the real killer and a particularly virulent strain of influenza induces a more potent immune response, possibly resulting in young people (who have very strong immune systems) suffering from increased damage compared to people who have a weaker immune systems.


The dotted line is the typical pattern of mortality (death) during an influenza outbreak. It is U-shaped, with the highest mortality seen in the very young and the very old. The solid line is the W-shaped pattern of influenza fatalities that was seen during the 1918 flu pandemic. It was highly fatal to three groups of people: the very young, people in the primes of their lives (teenage years to mid 30’s), and the very old. The increased mortality in very young and very old people in both pandemic flu situations and in a more typical flu season is due to a generally fragile state of the body during very early childhood and in the elderly.

The reason that we are discussing influenza today is twofold. First, the United States is presently in the midst of a flu pandemic that is arguably the worst to strike it in decades. Second, there is a disturbing amount of ignorance out there regarding this very important disease. Part of this ignorance is due to Americans’ unfortunate use of the term “flu” to refer to run-of-the-mill viral illnesses, such as the common cold. I often joke with my colleagues that if we called the common cold the “stomach AIDS” or “the 24 hour AIDS” no one would worry about using a condom when they visited a brothel. True influenza is a serious disease that kills around 20,000 Americans per year, and that’s during an average flu season. Your chance of getting the flu in any given year is around 1:15 (but the rate is much higher during pandemic years), so if you think that you get “the flu” every year and you’re “only sick for a day or two” then influenza probably isn’t the culprit of the illness that you are referring to. True flu makes your whole body hurt, makes you spike high fevers, causes snot to pour out of your nose, elicits a nonproductive cough that can be strong enough to make you vomit, and generally makes you sick as hell. Another issue is that the influenza virus changes every year and some strains make folks much sicker than other strains do, the problem being that it is hard to predict in advance which strains are going to be really nasty and which are going to be milder.


A map of the current influenza burden in the United States (2nd week of January 2015). This year there are at least two major strains of influenza circulating. The H3N2 strain of influenza A is the most prevalent strain. H3N2 has historically caused some of the worst influenza pandemics in terms of mortality (death). Influenza B is also circulating — fortunately influenza B tends to be a milder disease than influenza A in otherwise healthy people. Unfortunately, this isn’t necessarily true in susceptible populations (the very young, the very old, people with severe chronic diseases, people on immunosuppressant drugs, etc.). It also unfortunately means that you can get the flu more than once this season.

Let’s pause for a moment and step back to the basics of virology. Influenza is a virus, which means it is genetic material that is surrounded by a protein capsule. A virus is neither living nor dead. Like living things, viruses reproduce and change over time as they adapt to their environment. Unlike living things, viruses are incapable of reproducing on their own or of producing energy to power a metabolism. Instead viruses such as influenza must hijack the cells of living organisms to make more copies of the virus. A virus unable to do this goes extinct. In the simplest terms, a virus is a parasite that survives by infiltrating living cells (like mine and yours) and then transforming those cells into virus-making slave machines. The virus-infected cells crank out new viruses until either their energy is exhausted and the cell dies or until the cell is so filled with new viruses that it bursts open.


Influenza magnified 100,000x by an electron microscope.

There are two main classes of viruses. DNA viruses use the same genetic material that our human cells use to encode the “blueprints” for making new cells and for running those cells after they’ve been made. The smallpox virus is a good example of a DNA virus. Influenza on the other hand is an RNA virus. RNA is similar, but not identical, to DNA. A major difference is that RNA is significantly less stable than DNA. This lack of stability actually works in influenza’s advantage because it allows the virus to mutate extremely quickly. Most mutations result in a defective virus but some result in a functional virus that is different enough not to be recognized by the body’s immune system. This is called “genetic drift” and it is why there is a new influenza epidemic every year, and the reason why you can get the flu this year even if you have had it in the past. Influenza is also capable of another genetic trick whereby it can swap large portions of its genome (genetic material) with another similar, yet substantially different, strain of influenza. The proteins that are swapped are called hemaglutinin and neuraminidase and they are the “H” and the “N” of the common nomenclature for flu. In 2009, H1N1 caused a pandemic (fortunately the 2009 strain of H1N1 was fairly wimpy) whereas this year it is H3N2 that is the major problem. This swapping of H and N proteins often occur in birds and pigs before the virus hops back into a human host again. This is called “genetic shift” (aka: antigenic shift) and it is the cause of the flu pandemics that sweep the globe every few decades.


The smallpox virus magnified 370,000x by an electron microscope. The loop in the middle of the virus is its DNA genome.

Influenza is a seasonal disease in the temperate regions of the world, annually occurring during the winter in both the Northern and the Southern Hemispheres (remember that January is winter in the Northern Hemisphere whereas June is winter below the equator). No one really knows why this seasonality occurs, but a lot of researchers suspect that it has to do with people spending more time indoors and crowded next to one another when it is cold outside. Flu is spread both by droplets that are aerosolized when someone who is infected with influenza coughs or sneezes, and spread when an uninfected person touches something that a person with influenza has inadvertently deposited virus on by direct contact. The seasonality of influenza is not true in the tropics. At equatorial latitudes it is a year round disease and there can be multiple influenza outbreaks in a single year.


It isn’t very surprising that most strains of influenza are bred in the tropical and subtropical latitudes where poverty and poor hygiene often exist side-by-side subsistence farming on lands that humans share with hogs and birds (namely chickens). Flu loves to infect pigs, birds, and humans and its trans-species hopscotch is historically a prime culprit in the breeding of new pandemic strains of influenza. The 2009 H1N1 pandemic was a great example of this phenomena, producing a strain that fortunately turned out to be very mild but which very easily could have been a major killer. There is currently an extremely deadly form of avian flu in China called H7N9. The most recent mortality rate for H7N9 is 25% in people who are treated with modern medical care, including mechanical ventilation (aka: life support). In comparison, the mortality of the 1918 Spanish Flu was about 2.5%. Most people infected with this truly awful H7N9 strain of influenza have had direct contact with infected birds, usually chickens, but there have been sporadic cases of human-to-human transmission. Whenever this nasty virus mutates into a form that is readily spread from human-to-human a lot of people are probably going to die.

joni ernst 2

Skipping your flu shot before castrating hogs, a bad idea.

We have several ways to protect ourselves, and perhaps more importantly, our fellow humans, particularly infants, the elderly, and the chronically ill, against influenza. The first proven group of methods are staying home if you are sick, practicing good hand hygiene (hand sanitizer is probably best because most folks don’t wash their hands for the 15 seconds that you really need to to get them clean), and covering your mouth when you cough/sneeze. The proper way to cough/sneeze is into the crook of your elbow, not onto your hand, because your hand touches things and influenza can be spread by direct contact. Second, the seasonality of influenza in the temperate regions of the world is a blessing because it has allowed scientists to predict the strain of flu that will cause problems next year enough in advance to target the annual flu shot to the anticipated problem strain. Actually the flu shot contains the three most likely candidates for the next influenza outbreak and usually the scientists are correct and one of these three strains turns out to be the one that causes the outbreak. Most years the flu shot is 80-90% effective. This year it is only about 35% effective according to the CDC because influenza mutated (change) at the last minute, but 35% effective is still millions of cases of flu prevented and likely thousands of vulnerable lives saved. The flu shot, but not the nasal spray, contains DEAD flu virus and it cannot give you influenza. Some folks can get some mild flu-like symptoms for a day or two, usually the first year that they get the shot, due to their bodies’ immune response (which is what we want) to the dead flu antigens that are present in the vaccine (because they are the reason that it works). The only really common side-effect of the flu shot in my experience is a day or two of slight discomfort at the injection site. The intranasal influenza vaccine contains weakened live flu virus and it commonly does cause upper respiratory symptoms, especially a runny nose but also sometimes a dry cough, that are generally mild but that can be severe enough that it is recommended that asthmatics and other people with chronic lung diseases should not be vaccinated with the intranasal vaccine.


The Devil.


The Flu Shot. Not the same as the devil. Evidently this is a controversial distinction in some circles.

Our final line of defense against influenza is the anti-influenzal drugs, of which oseltamivir (Tamiflu) and zanamivir are the most effective. Unfortunately, the efficacy (how well they work) ranges wildly from year-to-year depending on the strain of influenza that is in circulation. Some years these drugs are >90% effective in decreasing the severity and duration of an influenza infection if taken within the first 48 hours of becoming symptomatic. Other years these drugs are completely worthless because the circulating strain of influenza is resistant to them. Fortunately, the H3N2 strain of influenza that is causing such trouble this year is very sensitive to oseltamivir (Tamiflu), which is why I have been writing prescriptions for it left and right for the past month. And speaking of my day job, that’s all for now folks. Stay well!


DOC’S FICTION BOOKS (Links to Amazon.com)!



The cannabinoid hypoyhesis-Color

DOC’S NONFICTION BOOKS (Links to Amazon.com)

Intrusive Memory E-Cover



Dr. Leonardo Noto

Author Bio: Dr. Leonardo Noto is the nom de plume of a former airborne battalion surgeon who is now in civilian practice. Dr. Noto is the author of four books and he also writes for a medical education corporation that assists medical students, interns, and residents as they prepare for the medical board examinations. Dr. Noto is the proud father of an extremely spoiled 16-month-old American Bulldog who enjoys slobbering everywhere and tearing up things that he is not supposed to! Dr. Noto is an amateur practitioner of muay Thai and Brazilian jiu jitsu and he recently began learning to play the guitar (but he is currently a quite terrible musician, as his neighbors will readily attest).

Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.com is intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!

The opinions voiced on this medical blog are solely the author’s own and they do not reflect the opinions or values of Dr. Noto’s employers, past or present. Dr. Noto’s medical blogs should never be used as supporting evidence for legal testimony — this is of course obvious to anyone who isn’t a complete moron, but some people are rather stupid.



1. Encephalitis Lethargica: http://nervous-system.emedtv.com/encephalitis-lethargica/encephalitis-lethargica.html

2. Dolin, Raphael. Epidemiology of Influenza. Jul 17, 2014. www.uptodate.com.

3. Dolin, Raphael. Diagnosis of Seasonal Influenza in Adults. Aug 15, 2013. www.uptodate.com.

4. Flu Map of the United States. http://www.cdc.gov/flu/weekly/usmap.htm.

5. What You Should Know for the 2014-2015 Influenza Season. http://www.cdc.gov/flu/about/season/flu-season-2014-2015.htm.

6. Smallpox Virus Electronmicrograph. http://en.wikipedia.org/wiki/Smallpox. Photo Credit: Content Providers(s): CDC/ Dr. Fred Murphy; Sylvia Whitfield.

7. Influenza Virus Electronmicrograph. http://en.wikipedia.org/wiki/Influenza. Photo Credit: Cynthia Goldsmith Content Providers(s): CDC/ Dr. Terrence Tumpey.

8. Fort Riley, Kansas Influenza Ward. http://en.wikipedia.org/wiki/1918_flu_pandemic#mediaviewer/File:CampFunstonKS-InfluenzaHospital.jpg. Courtesy of Wikipedia and the United States Government.

9. 1918 Influenza Mortality Chart. http://en.wikipedia.org/wiki/1918_flu_pandemic#mediaviewer/File:W_curve.png. Courtesy of Wikipedia and the CDC.

10. Awakenings Movie Poster. http://en.wikipedia.org/wiki/Awakenings#mediaviewer/File:Awakenings.jpg.

11.Encephalitis Lethargica Awakenings Oliver Sacks with text. Diane Sawyer interview. www.youtube.com. 

12. H7N9: Severe Illness, High Death Rate. http://www.medscape.com/viewarticle/804596.

13. The Influenza Pandemic of 1918. https://virus.stanford.edu/uda/.

14. Joni Ernst Campaign Image. http://www.blogforchoice.com/archives/2015/01/that-time-joni.html.

15. Guy Sneezing. http://en.wikipedia.org/wiki/Sneeze#mediaviewer/File:Sneeze.JPG. Courtesy of the CDC.

16. The Devil. http://en.wikipedia.org/wiki/File:The_Devil.jpg.

17. List of Vaccine Topics (Flu Shot Image). http://en.wikipedia.org/wiki/List_of_vaccine_topics

The New Controversy Over Blood Pressure and Cholesterol Guidelines – Part 2

Doc’s been running around like a chicken with his head cut off for the past month, but now I’m back and ready to give you the rundown on the new cholesterol guidelines, guidelines that are hot-off-the-press and, like their blood pressure brethren, are highly controversial. Published in Circulation: Journal of the American Heart Association, the new cholesterol guidelines are under attack for all sorts of reasons, and most of these reasons, in my opinion, are unfair and are largely coming from folks who don’t understand much of what we’ve learned in the past ten years with regards to treating hyperlipidemia (“high cholesterol”). So before we delve further, let’s take a step back and review the basics.

Cholesterol is a type of lipid (fat) that naturally occurs in the body and that is essential for making the membranes of the body’s cells and the protective sheaths of the axons of nerve cells, and for serving as the precursor to a plethora of essential hormones such as aldosterone (a salt-regulation hormone), estrogen, and testosterone. Unfortunately, cholesterol also plays an integral role in atherosclerosis, a disease that is characterized by the accumulation of fatty plaques in the walls of the blood vessels. Over time, these plaques can build up to such a degree that they narrow the blood vessels, causing a lack of blood flow to the peripheral organs. In severe instances, like in people with end-stage peripheral vascular disease, the blood flow can become so compromised that it results in the death of an organ (usually the legs in peripheral vascular disease).


Dry Gangrene caused by peripheral artery disease. Atherosclerotic plaques have decreased the blood flow to this persons feet so much that the 4th toe is beginning to die from lack of oxygen (remember that oxygen is carried by the blood). Notice that this patient has already had a previous amputation of the 1st toe (aka: “big toe”), probably due to the same disease process.

Worse yet, these atherosclerotic plaques are often unstable and can suddenly rupture. When this occurs the body’s platelets, tiny cell fragment that form blood clots, rush to the ruptured plaque and form a clot over it, aka: a thrombus. A thrombus can suddenly and completely close off a blood vessel. If this occurs in one of the coronary arteries, the arteries that supply the myocardium (heart muscle) with blood, then a heart attack is the result. If plaque rupture, followed by thrombosis, followed by arterial occlusion, occurs in the brain then the result is a stroke.  A heart attack is the death of heart muscle due to a disruption of its blood supply whereas a stroke is the death of brain cells due to the same process – and this is why your doctor cares about your cholesterol levels.


A good illustration of how an atherosclerotic plaque can rupture–>thrombosis–>death of myocardium (heart muscle). This is medically called a “myocardial infarction” and is known in layman’s terms as a “heart attack.”

A few decades ago drug companies began discovering medications that lowered the levels of cholesterol in the blood. The thought at the time was that since cholesterol plays such an integral role in the formation of atherosclerotic plaques, and since people living in western/developed countries tend to have much higher levels of cholesterol in the blood than folks who live on rice and beans in the developing world, that lowering cholesterol levels would help prevent the development of atherosclerosis and its sequelae—heart attacks, peripheral vascular disease, strokes, aortic aneurysms, and more. This idea caught on rather quickly and before long everyone over the age of 40-50 was getting their cholesterol checked at least once a year by their doctor and being put on medication if their bad cholesterol (aka: LDL) was above 160mg/dL, with lower numbers like 130mg/dL, 100mg/dL, or even 70mg/dL being used as the goal for folks with known heart disease, diabetes, or who had suffered from a stroke. The problem is that while there are lots of drugs that lower cholesterol levels, only one category of these drugs has been scientifically shown to decrease the risk of death from atherosclerotic disease. These drugs are called statins.


This is red yeast rice, a rice fermented with a specific mold that has been used medicinally and as a food substance in China for thousands of years. In the 1970’s the drug companies started investigating red yeast rice and they were able to isolate the cholesterol-lowering substance that it contains. This substance was patented under the name “Lovastatin” and the first statin drug was born. Lovastatin is a fairly low-potency statin and much more powerful derivatives have since been designed by the pharmaceutical industry. The most powerful statin drug is rosuvastatin (aka: Crestor), closely followed by atorvastatin (aka: Lipitor).

Niacin, the fibrates, bile acid binding resins, and more—all of these drugs significantly lower cholesterol, but this lowering of cholesterol has NOT been shown to lower mortality (risk of dying) from atherosclerotic disease. But the statins class of cholesterol-lowering drugs does decrease mortality from these atherosclerotic diseases, including in people who have had heart attacks and strokes in the past. How the heck does that make sense? All of these classes of medications lower cholesterol, but only the statins have a mortality benefit (decreased risk of death) from cholesterol plaque-induced diseases. Why?


Statins have been proven in study after study to prolong the inevitable trip to the grave for people with atherosclerotic disease or who are at high risk of atherosclerosis. None of the other cholesterol-lowering drugs have shown this benefit!

Physicians and scientists think that the reason statins are so beneficial for patients with atherosclerosis, while all of the other cholesterol lowering drugs are of dubious benefit at best (and of no benefit at worst), is because statin medications have other heart and blood vessel protective effects in addition to the lowering of cholesterol levels. The mechanism of this effect is still being investigated, but the most widely accepted theory is that statins also stabilize preexisting atherosclerotic plaques, the plaques that have been building up in the walls of every Western person’s arteries since childhood due to the unhealthy Western/American diet. These stabilized atherosclerotic plaques are less likely to rupture and it is the rupturing of these plaques, followed by thrombosis, that is responsible for the overwhelming majority of heart attacks and strokes.


This illustration shows the slow buildup of cholesterol and inflammatory cells in the walls of a small artery. The yellow substance is a combination of cholesterol and inflammatory cells — an atherosclerotic plaque. If you have lived in a Western/developed country for most of your life you almost certainly have at least some plaques in your arteries. We know this because even Western teenagers (who have died in car accidents, etc.) have been found to have some  plaque buildup. Most heart attacks and strokes are caused by the rupture of an unstable plaque–>thrombosis–>sudden and complete occlusion of an artery. Statins decrease the buildup of these plaques by lowering cholesterol levels in the blood but also probably stabilize preexisting plaques and make them less likely to rupture. Aspirin is heart protective because it inhibits the action of platelets, the cells responsible for thrombosis of ruptured plaques. The combination of a daily aspirin and a statin is more protective than either drug alone.

The new cholesterol guidelines are based on the recommendations of a joint panel of experts from the American College of Cardiology (ACC) and the American Heart Association (AHA) and these guidelines were published in November 2013. Before the publication of the new guidelines the cholesterol goals that your doctor was promoting were based on the findings of an older expert panel called ATP III (published in September 2002). The ATP III guidelines used an algorithm to determine how high risk a particular patient was for having atherosclerotic heart disease and then recommended a goal cholesterol level based on the calculated risk. Practicing physicians then used a variety of medications to attempt to achieve this cholesterol goal, reevaluating their progress by checking lots of cholesterol blood levels until the cholesterol blood level was in the goal range. The 2013 guidelines do away with most of this based on the best medical/scientific research currently available. And as we discussed above, the best and most current research essentially shows that statin drugs make you live longer if you have atherosclerotic disease and that none of the other cholesterol-lowering drugs have this effect.


So here’s the new ACC/AHA guidelines in simplified form — drum roll!


A)     You should be on a statin medication if you fall into one of these four groups:

1.       If you have atherosclerosis.

2.       If your LDL cholesterol (bad cholesterol) is >190mg/dL.

3.       If you are a diabetic who is aged 40-75.

4.       If your estimated 10-year risk of atherosclerotic heart disease is >7.5% based on this risk calculator: http://my.americanheart.org/cvriskcalculator.

B)      Instead of trending cholesterol blood levels, your doctor should use the new AHA/ACC algorithms to determine if you should be on a high-intensity statin, a moderate-intensity statin, or a low-intensity statin. In other words, instead of obsessing over a blood cholesterol goal we should instead be trying to reach a goal dose of a statin medication.


QUESTION #1: My cholesterol is great on (insert medication name – niacin, fenofibrate, fish oil, etc.). Why the heck should I start taking a statin?

ANSWER: It’s nice that your cholesterol looks good on paper, but remember that your cholesterol level is only a number. Only statin drugs have been shown to decrease the risk of death from atherosclerotic disease. No one argues that you can lower cholesterol numbers with other medications, the question is whether that lowering of cholesterol is doing any good! I repeat, only statin medications have been scientifically proven to lower the risk of death from atherosclerotic disease. This is probably because statin medications have other protective effects besides just lowering cholesterol.

QUESTION #2: I see a lot of commercials on television from lawyers telling me how bad statin drugs are. Do you really think that I should be taking these medications?

ANSWER: Yes, if you fit into one of the four above listed categories, with the caveat that every patient is different and that I think even more strongly that you should follow your personal doctor’s advice (and I’m not your doctor). All medications have side-effects and statins are no exception. Statins can be hard on the liver and they can also cause myalgias (muscle pains) in susceptible people. If you have a predisposition to diabetes, they can probably can push you over into the official diabetic category faster than you would have gotten there otherwise. With that said, in people who have atherosclerosis or who are at very high risk for atherosclerosis the side-effects of not taking a statin medication are also very high and very dangerous, namely a substantially increased risk of heart attack, stroke, and death! In my experience, in the overwhelming majority  of patients with atherosclerosis or who are at high risk of atherosclerosis the risks of not being on a statin greatly outweigh the risks of taking one of these medications — I do know people who are exceptions, but they are few and far between.

CRITICISM #1: What’s the deal with this new risk calculator? I heard that it’s going to put a lot more people on statins.

REPLY: Yeah, no risk calculator is perfect, but a recent (March 2014) study in the Journal of the American Medical Association found that the new risk calculator works pretty well when used for Americans (in the same issue the calculator didn’t work so well when used for populations in Europe, but that’s not who its designed for). Yes, the new risk calculator does recommend statin therapy for lots of people who probably wouldn’t have been put on these medications under the old guidelines, but you have to remember that we’re talking about the disease (atherosclerosis) that is the #1 killer of Americans, so it’s not all that surprising that lots of people are found to be at risk by a good risk calculator!

CRITICISM #2: Isn’t this just a ploy by the drug companies to get lots of people to take their medications?

REPLY: Most statins are generic now, so in my opinion this isn’t a fair criticism.

QUESTION #3: I can’t tolerate statin drugs. Isn’t there an alternative medication?

ANSWER: This is anecdotal based on my personal experiences with patients, but the overwhelming majority of patients that I’ve treated who reported being “statin-intolerant” weren’t really. I have had a handful of (mostly) little old ladies who really couldn’t tolerate these drugs, but it is rare and in my experience most people with reported statin-intolerances are really “lawyer commercial intolerant.” Statins are a big business because the disease process that they treat is so prevalent. Most of the possible alternative medications also have a ton of potential side-effects, you just don’t hear about them on TV because statins are where the potential money is for the class action lawsuit attorneys. Remember, none of the alternative drugs have shown a mortality benefit (reduction in the risk of death) in patients with atherosclerotic disease. Only the statins are proven to do this!

QUESTION #4: What’s the deal with this “high-intensity, moderate-intensity, and low-intensity” statin therapy guideline?

ANSWER: Some statin drugs are more powerful than others. The new ACC/AHA guidelines have special algorithms that your doctor can use to determine how powerful of a statin you should be on. More powerful statins tend to be more heart and artery protective, but they also tend to have more side-effects. Examples of low-intensity statins are low-dose lovastatin and pravastatin while atorvastatin (in a high dose) and rosuvastatin are high-intensity drugs.



A dark historical thriller based in the American Revolution. Free on Smashwords for your e-reader April 2014. Click on the cover image!


1. Stone et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. November 12, 2013.

2. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA. 2001;285(19):2486-2497. doi:10.1001/jama.285.19.2486.

3. Muntner, et al. Validation of the Atherosclerotic Cardiovascular Disease Pooled Cohort Risk Equations. JAMA. 2014;311(14):1406-1415. doi:10.1001/jama.2014.2630.

4. Dry Gangrene: http://commons.wikimedia.org/wiki/File:Dry_gangene_4th_toe.jpg

5. Heart Attack: http://simple.wikipedia.org/wiki/File:Heart_attack-NIH.gif

6. Red Yeast Rice: http://commons.wikimedia.org/wiki/File:Red_yeast_rice_wine2.jpg

7. Tombstone: http://commons.wikimedia.org/wiki/File:OahuCemetery-RevSamuelCDamon-tombstone.JPG

8. Atherosclerotic Plaques: http://upload.wikimedia.org/wikipedia/commons/0/0e/Blausen_0227_Cholesterol.png

9. Drum Roll/Drummer Boys Image: http://en.wikipedia.org/wiki/File:Sprit_of_%2776.2.jpeg


Dr. Leonardo Noto

DISCLAIMER: Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.com is intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!

The opinions voiced on this medical blog are solely the author’s own and they do not reflect the opinions or values of Dr. Noto’s employers, past or present. Dr. Noto’s medical blogs should never be used as supporting evidence for legal testimony — this is of course obvious to anyone who isn’t a complete moron, but some people are rather stupid.

The New Controversy Over Cholesterol and Blood Pressure Guidelines

As much as I’d love to blog about UFC or great medical movies again, let’s take a break from the fun stuff and discuss something that is really important — the new hypertension (blood pressure) and cholesterol guidelines that your doctor is probably already using whether you realize it or not. Your doctor determines your goal cholesterol and blood pressure based on the medical opinion of internationally recognized panels of experts, namely the Joint National Committee for blood pressure and the American Heart Association and the American College of Cardiology consensus statement for cholesterol. In this edition of The Health and Medical Blog with a Personality we’re going to examine the new blood pressure guidelines and next time we’ll delve into the controversy over the new cholesterol targets.


Talking about doctors fighting over blood pressure guidelines isn’t quite as exciting as watching these guys go at it, but it’s a hell of a lot more important…

“For every 20-mmHg increase in SBP beginning at 115 mmHg, or 10-mmHg increase in DBP beginning at 75 mmHg, mortality from ischemic heart disease and stroke are doubled” [Reference #1. Note: SBP = the top number and DBP = the bottom number. More on that later]. The problem with hypertension is that you don’t feel sick, even though you really are, and by the time that you DO feel sick you have a serious problem on your hands — if you’re lucky enough to still be alive, that is. The good news is that dangerously high blood pressures are easy to detect via simple screening in your doctor’s office and that hypertension is usually pretty easy to treat. Fully 1/3 of all Americans have high blood pressure (2/3 if your older than age 60) and the cost to our society of the preventable heart attacks and strokes that these people needlessly suffer every year is greater than $100 billion dollars!


A right-sided hemorrhagic (bleeding) cerebral vascular accident (stroke) with midline shift of the brain (not good) seen on a CT scan. Strokes come in two forms: hemorrhagic and ischemic. Hemorrhagic strokes occur when a blood vessel in the brain “pops” open, often because of uncontrolled high blood pressure. Ischemic strokes occur when a clot blocks an artery in the brain. Uncontrolled hypertension substantially increases your risk for both types of stroke.

Physicians have known for at least the past few centuries that walking around with a sky high blood pressure was really bad for you. Even before we had blood pressure cuffs, doctors realized that people with abnormally strong pulses had a habit of keeling over prematurely. The problem until the late 1950s was that we didn’t have very many effective ways to treat hypertension. Yes, there was the salt-restrictive diet, that worked (and still does work) wonders in a minority of hypertensives, and we had some really nasty drugs like phenobarbital (commonly used to anesthetize lab animals prior to execution and dissection these days), but there weren’t any good choices to treat the average High Blood Pressure Joe without causing side-effects that were arguably worse than the disease. This all changed in the ’50s with the introduction of thiazide diuretics, an effective class of medications for high blood pressure with relatively few side-effects. Over the next few decades a plethora of effective classes of antihypertensives entered the market and medicine was changed forever (now the problem is getting patients to take their damn medications…).


Another potential catastrophic sequelae (side-effect) of untreated hypertension is aortic dissection. Essentially the unravelling of the largest artery in your body (the aorta) by untreated high blood pressures. The weakened aorta then ruptures and rapidly spills the majority of the body’s blood into the chest cavity, resulting in sudden death. 

The Joint National Committee (JNC) was established in the mid-1970’s to provide physicians with guidance over how and when to use our new armamentarium of antihypertensive drugs. Every 5-10 years JNC releases a report that most doctors use as their guide regarding how and when to treat your high blood pressure. JNC is a group of experts in the treatment of high blood pressure, the best-of-the-best, who get together and mull over the results of clinical trials (really big and expensive scientific studies) and then determine what your goal blood pressure should be and what treatments your doctor should use to get it there based on these scientific studies. Until a few weeks ago the results of the 7th JNC meeting, JNC-7 (released in 2003), was the final word on the treatment of hypertension and, whether you knew it or not, was almost certainly the source of the blood pressure goals and treatment guidelines that your doctor was preaching to you every time you went in for a checkup. That changed on the 18th of December 2013 with the much anticipated release of JNC-8 in the Journal of the American Medical Association.


Another nice artist’s rendition from the Wiki of the cardiovascular (“heart and blood vessel”) complications (“bad stuff that happens”) due to uncontrolled hypertension.

The biggest difference between JNC-7 and JNC-8 is that the JNC-8 commission only looked at the results of Randomized Controlled Clinical Trials, the highest quality scientific studies, whereas all of the prior JNC groups (including JNC-7) also considered the results of lower quality clinical evidence, including “expert opinions (the ‘two-cents’ of certain medical big shots),” when they formulated their guidelines. Let’s look at what’s changed and then we’ll argue about it!








Blood Pressure Goal


Age >60 : <150/90

Age <60 : Only treat if Diastolic Blood Pressure (the bottom number) is >90. If treated, the goal is <140/90.



Blood Pressure Goal if Diabetic or Chronic Kidney Disease





1st Drug Choice if Medication is Required


Black Patients : Hydrochlorothiazide or Calcium Channel Blockers


Nonblack Patients: ACE Inhibitors/ARBs, Calcium Channel Blockers, or   Hydrochlorothiazide.

Note: Black patients tend to response less to the ACE Inhibitor/ARBs class of blood pressure medications than other populations of people do.



Other Acceptable Drug Choices

ACE Inhibitors/ARBs, Beta Blockers, Calcium Channel Blockers

Same as Above (Beta Blockers are no Longer Recommended as 1st or 2nd   Line Treatments For Hypertension by JNC-8)



The most surprising difference in JNC-7 vs. JNC-8 is the new recommendation NOT to begin treatment for people older than age 60 unless their blood pressure is >150/90 (instead of the old guideline of >140/90). The JNC-8 panel only looked at the very best clinical trials and they found evidence that 150/90 was the point where the benefits of treating folks with medications outweighed the side-effects of those medications. With that said, JNC-8 used very high criteria to define what a “good” study is. To add fuel to the debate, virtually all of the studies out there looking at blood pressure weren’t actually designed to help answer the questions JNC-8 was asking, questions like “when should we treat high blood pressure” or “what kind of drugs should we use to treat high blood pressure.” Rather, even the best of these clinical trials were generally drug company sponsored studies that were evaluating whatever particular drug the sponsoring company was trying to sell.


Drug companies fill a vital role in modern medicine, designing the life-saving medications, vaccinations, and medical devices that have revolutionized the human experience in the past century. However, they also do a lot of ethically “questionable” things, like hiring former cheerleaders to market drugs to male doctors, bribing doctors with “continuing medical education” cruises and golf outings, using indigent people in piss-poor countries as their research subjects (and sometimes “doctoring” the results of these studies), and promoting drugs for “off-label” uses of questionable value (and etc., etc.). Studies that are funded by drug companies are important because who the heck else is going to fund this stuff (!), but remember to take them with a grain of salt.

There was a vocal minority in the JNC-8 commission (see their dissenting paper listed in the “References” section below) that argues that there is a clear decline in heart disease and stroke when  <140/90 is used as the blood pressure goal and that the side-effects of treating people to this goal, especially increased falls, don’t really become a significant problem in most patients until they are older than age 80. This minority of experts argues that <140/90 is a more appropriate goal for patients who are younger than age 80. The take home message is that this is still very much a topic of debate and that you should have a discussion with your doctor regarding your personal blood pressure goal since your physician knows you better than the experts who wrote the general guidelines (e.g. Are you at high risk for falls? Then maybe your personal blood pressure goal should be >150/90. Have you had a hemorrhagic stroke in the past but aren’t a particularly high fall risk? Then maybe your personal blood pressure goal should be lower.).


A large hematoma (essentially a huge bruise caused by a deep collection of blood) after a hip fracture. Untreated hypertension is a leading cause of disability and death due to preventable strokes, heart attacks, kidney failure, and aortic dissections (etc.). However, overtreated hypertension can also be dangerous due to increased risk of falls.


A fractured (broken) hip on X-ray. Falls are a common cause of hip fracture in the elderly, and hip fractures are a common cause of permanent disability and even death in this population. On the other hand, strokes and heart attacks are also a rather common cause of disability and death in the elderly, and untreated (or undertreated) hypertension substantially increases your risk of having both. As with most things in medicine, the treatment of hypertension is a balancing act that should be managed by an experienced physician — and sometimes there isn’t a right answer, just the least wrong one.

The other major changes were the higher (<140/90 instead of <130/80) blood pressure goal for diabetics and persons with chronic kidney disease, the consensus not to treat people younger than 60 unless their diastolic blood pressure (the bottom number) was >90, and the removal of beta blockers from the recommended 1st or 2nd line blood pressure medication treatment options. The higher blood pressure goal for diabetics and in chronic kidney disease were based on an expert consensus statement because high quality evidence is limited (i.e. there isn’t a lot of it out there) — the expert consensus of the JNC-8 panel is at odds with the expert consensus statements of several prominent diabetes and kidney organizations, so again, speak with your doctor to determine what you personal goals should be based on your unique medical situation because this is still a gray area issue.

The blood pressure goal for folks younger than age 60 also suffered from a paucity of quality evidence. In my personal opinion a blood pressure goal of <140/90 is reasonable for most folks who are younger than 60 (you’re not likely to be a high fall risk at this age), but you should be aware that the best clinical evidence only supports treating hypertension in this age group if the diastolic (bottom number) blood pressure is higher than 90. The final major change in JNC-8 was regarding beta blockers for the treatment of hypertension. Beta blockers are good drugs for protecting the heart when someone has heart disease. However, they tend to be wimpy drugs when used soley for the treatment of hypertension, which is why they aren’t recommended by JNC-8 as a 1st or 2nd line drug for folks with high blood pressure anymore. With that said, a lot of patients with high blood pressure have another medical condition like heart disease for which beta blockers are indicated, so don’t be surprised if your doctor prescribes one of these medications if this describes you.


This is the chemical structure of carvedilol, aka: Coreg, a type of beta blocker medication. The beta blockers studied by JNC-8 (the ones that don’t work well for high blood pressure) were “cardioselective” beta blockers. Carvedilol, on the other hand, is a “broad spectrum” beta blocker that additionally blocks alpha receptors, another important drug target in the treatment of hypertension. In my clinical experience, drugs like carvedilol are substantially more effective in the treatment of hypertension than the cardioselective beta blockers that  the JNC-8 panel studied. Unfortunately, JNC-8 didn’t address this category of drugs.

In a nutshell, as with most major guidelines in medicine, JNC-8 begged two questions for every one that it answered. Remember that guidelines are an important part of medicine, but also remember that you are a unique person, with a unique constellation of health attributes and health problems, and that you should always discuss your treatment options and goals with your personal physician to make certain that you are both on the same page when it comes to your health!

Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis. Amazon Link to Doc’s Writing:  http://www.amazon.com/Leonardo-Noto/e/B00ATVOMCW/ref=ntt_dp_epwbk_0

NOTE: The Life of a Colonial Fugitive — my dark historical thriller — is free for your e-reader at http://www.smashwords.com/books/view/215272. Thanks for reading!

Author Bio: Dr. Leonardo Noto is the nom de plume of a former airborne battalion surgeon who is now in civilian practice. Dr. Noto is the author of four books and he also writes for a medical education corporation that assists medical students, interns, and residents as they prepare for the medical board examinations. Dr. Noto is the proud father of an extremely spoiled 20-month-old American Bulldog who enjoys slobbering everywhere and tearing up things that he is not supposed to! Dr. Noto is an amateur practitioner of muay Thai and Brazilian jiu jitsu and he recently began learning to play the guitar (but he is currently a quite terrible musician, as his neighbors will readily attest).

Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.com is intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!

The opinions voiced on this medical blog are solely the author’s own and they do not reflect the opinions or values of Dr. Noto’s employers, past or present. Dr. Noto’s medical blogs should never be used as supporting evidence for legal testimony — this is of course obvious to anyone who isn’t a complete moron, but some people are rather stupid.


Jackson, James H. et al. Blood Pressure Control and Pharmacotherapy Patterns in the United States Before and After the Release of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment. J Am Board Fam Med. 2008;21(6):512-521. http://www.medscape.com/viewarticle/583572

Basile, J and Ventura, H. A Historical Look at Hypertension: Celebrating 100 Years with the Southern Medical Association. Southern Medical Journal:  December 2006 – Volume 99 – Issue 12 – pp 1412-1413. http://journals.lww.com/smajournalonline/fulltext/2006/12000/a_historical_look_at_hypertension__celebrating_100.36.aspx

James, Paul A. et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). Journal of the American Medical Association. doi: 10.1001/jama.2013.284427. Published online December 18, 2013.

Wright, Jackson T. et al. Evidence Supporting a Systolic Blood Pressure Goal of Less Than 150 mm Hg in Patients Aged 60 Years or Older: The Minority View. Annals of Internal Medicine. 2014 American College of Physicians.

Brett, Allan S. JNC 8 Has Finally Arrived. NEJM Journal Watch. January 15, 2014. Vol. 34 No. 2.

CT of Hemorrhagic Stroke. http://en.wikipedia.org/wiki/Stroke
Haggstrom, Mikael (Wikipedia/Wikimedia Commons). High Blood Pressure Complications Graphic. http://en.wikipedia.org/wiki/File:Main_complications_of_persistent_high_blood_pressure.svg