Doctor Q&A: Can coming off statins increase your risk of a heart attack? Dr Renee Hoenderkamp answers your questions

My physician is recommending I take statins due to slightly elevated cholesterol levels but I have read coming off statins can increase your risk of a heart attack or stroke - is this true?   

This is interesting, not just from what you are asking but the other parts of the question that I will tackle first!

You say that you have slightly elevated cholesterol and I would always ask my patients if they would prefer to try and tackle their cholesterol levels with lifestyle changes before a medication when their levels are only slightly elevated. This would include:

Eat heart-healthy foods

• Reduce saturated fats
• Eat foods rich in omega-3 fatty acids
• Eliminate trans fats. Trans fats, sometimes listed on food labels as "partially hydrogenated vegetable oil"
• Add whey protein
• Increase soluble fibre

Exercise / increase your physical activity

Work up to at least 30 minutes of exercise five times a week or vigorous aerobic activity for 20 minutes three times a week.

Quit smoking - Within a year of quitting, your risk of heart disease is half that of a smoker

Lose weight

Drink less alcohol – less than 14 units a week and less

Doing all of the above has to be better than taking medication if it works.

If not working then the NICE Guidance changed last year to say that statins can now be considered as part of shared decision-making for people who haven’t had a heart related event with a 10-year CVD risk score of less than 10 percent. This score is worked out using a tool called the QRISK3 calculator found here.

Now to your question. There has been some data previously to suggest that when you stop statins you get a rebound hypercholesterolaemia, in other words, stopping statins makes your cholesterol climb even higher than before you started and so increases your risk of strokes and heart attacks. This however has not been shown to be true . What is true is that your cholesterol will return to the same levels before starting the statin so your risk remains as it was then and does not catapult as a result of stopping the statin.

The other consideration is if you have had already had a cardiac event, a stroke or heart attack in which case the decision changes. So I would generally suggest to a patient with only slightly elevated cholesterol and who hasn’t had a cardiac event previously, that they might want to try lifestyle changes first and retest in six months. But at the end of the day, the decision to start any medication can only be taken by the patient once they have all of the data, risks and benefits available. I often point patients to Doctor Zoë Harcombe, who picks apart the data on cholesterol and statins.

I hate flying and my fears have intensified after the Singapore Airlines turbulence.  I have a flight in a few months and my anxiety is driving me crazy. How can I confront my fear of flying? 

I am honestly writing this whilst on a flight and I understand that the recent turbulence tragedy onboard the Singapore flight was shocking for all and must have understandably heightened the commonly seen fear of flying for many.

There are of course short acting medications that can help with the flight itself, but the best solution is dealing with the psychology behind the fear, as that is what it is: a psychological fear.

Whilst hearing that you are more likely to die in a car crash isn’t likely much help. It is always good to put things in perspective; the chance of dying in a motor vehicle accident is approximately one in 93. In contrast, the chance of dying in a plane crash is so rare that the odds cannot even be calculated.

Chatting to a psychologist friend, she explained that it isn’t usually the actual fear of flying that is the issue but other aspects of the process such as disliking heights, fears of dying, being in small spaces (claustrophobia), motion sickness or being worried that a fellow passenger may open a plane door mid-flight. Some people worry about catching a virus or bacteria and some are just worried about being anxious and how they will cope.

So long term (not for that flight next week or even month), using psychology input to unpick and then learn to deal with your fear, usually by CBT, is key and does work. Alongside this, coping strategies on board such as distraction (films, games, books, writing, puzzles), careful seat selection to make you feel more at ease with positioning, research the safety of air travel (which is the safest travel there is), talk to the flight attendants, they are well trained to help, and maybe if you are feeling really bold, before flying, take a flying lesson as emersion therapy!

So whilst long term treatment is the best, there are some things you can try short term. There are herbal remedies for anxiety and aimed at calming. You could try Bachs Rescue remedy as lozenges or drops for under the tongue. Use camomile tea/lozenges and lavender inhalation leading up to and during the flight and listen to calming music on headphones to stay relaxed.

If this isn’t helping, your GP may prescribe a low dose of diazepam to take just before the flight but there is no obligation for them to do this and it is not recommended by the NHS or aviation organisations, because you have a responsibility to be alert at all times on the flight and diazepam is a sedating medication. Having said this, many people sleep through flights, often using over the counter sleeping aids or alcohol and so doctors will weigh up the risks of you being anxious and having a panic attack mid air with a very low dose calming medication so it is definitely worth a visit.

Meantime the best advice whilst on the flight is to dream of the amazing holiday awaiting and keep your seat belt done up at all times when not up and off to the loo!

I have shaky hands and I can barely hold a cup nowadays. I'm in 60s and it weighs heavily on my mind - should I be worried?  

So sorry to hear this. I sat next to somebody a little older than you on a flight recently who was suffering really badly with a tremor and it made everything, from holding a drink to opening the seat table a major task. It bought home to me how debilitating tremor is.

Tremors definitely arise with increasing age and tend to fall into two categories;

Action Tremors: Shaking as you’re trying to perform a movement/task. Eg reaching for a spoon, holding a cup. These tremors are caused by muscle contractions and usually are not a sign of a neurological disorder.

Resting Tremors: Constant tremor in action moves or stationary. Resting tremors can be a sign of an underlying neurological disorder, for example, Parkinson’s disease.

Most tremors will be benign, but some may be a developing health condition and so it is important to get it checked out, as sooner is always better in terms of treatment.

In the meantime, benign tremors can be a response to;

Triggers

*Anxiety * Fatigue * Chronic stress

* Low blood sugar *Too much caffeine

* Excess alcohol or nicotine consumption

See if any of these could be making things worse for you.

Medications

* Asthma medication *anti-seizure medications *stimulants (eg for ADHD)

* Mood stabilizers * immunosuppressants *hypertension meds

* Antivirals and antibiotics * cancer treatments

Vitamin deficiency

Vitamin B12 deficiency can start to affect nerve health, resulting in tremors.

Treatment

Assuming you have seen your GP and there is no underlying health condition causing your tremor, then there are things you can do;

• Identify Triggers: Know which factors worsen your tremor then limit them if you can.
• Medications: Discuss side effects of medications with your GP and any interactions.
• Activities of Daily Living: Ask your doctor for an assessment of how well you can cope with activities of daily living and any aids that might help.

• Make Lifestyle Changes: Avoid caffeine and alcohol and take up yoga or Tai Chi.

• Medication: If the above does not help, there are treatments to help treat tremors, including medication, Botox injections, high-frequency ablation or deep brain stimulation.

So long answer short, you probably have no need to be worried but you do need to be assessed, just in case your tremors are being caused by a developing health condition. Good luck.