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Co-Enzyme Q10 and Statin Therapy
Co-Enzyme Q10 and Statin Therapy - General Points
Statin Induced Diastolic Dysfunction - Reversible with CoQ10 Administration
Statin Induced Myopathy - Reversible with CoQ10 Administration
Statin Therapy +/- CoQ10 - Effect on Endothelial Function
Co-Enzyme Q10 and Statin Therapy - General Points
Statin drugs waste Co-Enzyme Q10 - it's as simple as that. If you take a statin drug, your CoQ10 levels will plummet, and this will compromise the function of your heart. If you consider that CoQ10 supplementation has been shown to be of value in heart, brain, and kidney disease and in athletes, then you can understand some of the side-effects of statin therapy.
We can obtain CoQ10 from our diet, where it is present in brain, liver, kidney, heart, and to a lesser extent muscle, of the animals we eat. But neither evolution or our maker anticipated that we might become CoQ10 deficient, so if you are low in CoQ10 you can't make up increasing CoQ10 absorption from your diet. Unless you want to go on a high monkey brain diet, you need to take a CoQ supplement if you are low in CoQ. If you have established heart disease, or as discussed below, if you are taking a statin drug, then you should be on CoQ10.
CoQ10 is as important to the body as is cholesterol. Every cell can make cholesterol from carbon fragments of sugar and fat molecules that are not used to generate energy. CoQ10 is synthesized on an off-shoot of the cholesterol biosynthetic pathway, so if you can make cholesterol you can make CoQ10. Statin drugs (HMG Co-A Reductase Inhibitors) block the production of cholesterol by blocking the action of HMG Co-A Reductase. By poisoning this enzyme, they block the production of cholesterol, and inevitably they block the production of Co-Enzyme Q10 - thus:
Statin drugs compromise energy production in the heart
Statins compromise energy production in every cell of your body
The drug companies freely admit this, and then point out that their original drug safety studies (carried out in young, healthy people, who have plenty of CoQ10 - the initial safety studies were not carried out in people with heart disease who will be CoQ10 deficient), didn't show that this drug induced CoQ10 deficiency was a problem. Animal studies have shown that statin therapy lowers blood and heart tissue CoQ10 levels by 50%. CoQ10 supplementation, provided along with statin therapy, increased CoQ10 levels back to normal, without interfering with the cholesterol lowering effects of statin drug therapy. These same studies show that statin therapy, carried out without CoQ10 supplementation, decreased cardiac function. Those of us who practice integrative cardiology or nutritional medicine see people with statin induced pump dysfunction all the time. The typical patient has some form of pre-existing heart disease, often a cardiomyopathy. Even though coronary angiography demonstrates the absence of plaque deposition, a statin drug is prescribed because the patient's cholesterol level is above 200 mg/dl. Now, if you are 70 years old and your arteries are normal, I just don't see the rationale for lowering your cholesterol. If the cholesterol hasn't affected your vessels, do we really need to put you on an expensive, potentially toxic drug to lower it? We will, because statin therapy has become ingrained in American medicine, and in American culture. The TV adds are quite effective and you want something done so your doctor will put you on a statin. The statin will lower your myocardial CoQ10 content, which is low in the first place because you have a cardiomyopathy or some other form of heart disease. As your CoQ10 level falls in your blood, within your heart cells, and within the mitochondria of your heart cells, ATP energy production will fall. Diastolic function, the ability of the hear to relax and allow passive filling, is more energy intensive then is cardiac contraction, and it will fall off first. Diastolic dysfunction due to statin therapy creeps up on you and is often not recognized by your physician, but when you start huffing and puffing on the golf course (and your physician can't "find anything wrong"), then you know that you have it. Systolic function will falter later, but this is typically seen (or recognized) only in patients with pre-existent systolic dysfunction and a low baseline ejection fraction. Statin induced pump dysfunction has been reported in the literature, typically as case reports, and I see it not infrequently, but you will never see a randomized, double blind study of statin therapy and pump dysfunction because no one would pay for it and because it would be unethical. A report was also published, showing that statin therapy compromised peak cardiac performance in a young athlete. A study of CoQ10 in statin induced diastolic dysfunction has been done and proves the point:
Statin Induced Diastolic Dysfunction - Reversible with CoQ10 Administration
This study looked at diastolic function, the ability of the heart to relax and fill passively, in 14 individuals who were to begin statin therapy to address an elevated blood cholesterol level. Cardiac echo measures of diastolic function, the E:A ratio (a high ratio is good) and isovolumetric relaxation time (a short time is good) were measured, before and 3 months in to therapy with Lipitor at a dose of 20 mg/day.
Uh Oh - Diastolic function was compromised by statin therapy. They don't talk about this much in the TV adds, but here it is, published in the American Journal of Cardiology. 10 of the 14 patients had at least one measure of diastolic function convert from normal to abnormal; the 4 who didn't had higher pre-treatment CoQ10 levels. OK - we've demonstrated that statin therapy compromises diastolic function - but can we reverse the problem with Co-Q10 supplementation? These statin treated patients were begun on CoQ10 at a dose of 300 mg/day; the third column in the above charts gives you the result. The problem was solved. We can give you statin therapy, but if we also provide you with CoQ10, then you will not suffer from statin induced energy deficiency. We do not have similar, published studies showing that CoQ will predictably improve systolic function or ejection fraction in statin treated patients, but I do see this in my practice. Statin therapy often leads to an elevation in liver chemistries, likely on the basis of energy dysfunction within the liver. Usually, but not always, liver chemistries will return to baseline with the addition of CoQ10 and liver protective nutritionals such as N-Acetyl Cysteine and Silymarin (known as Mild Thistle). Muscle aching and fatigue, first involving the large muscle of the the truck and thighs, is another common side-effect of statin therapy. I wonder why?
Statin Induced Myopathy - Reversible with CoQ10 Administration
Forty one patients with muscle aching felt to be due to stain therapy were evaluated in this study. The subjects were asked to rate their pain on a 1 - 10 scale, and where then randomized to receive Vitamin E 400 IU/day or CoQ10 100 mg/day over 30 days, followed by a reassessment of their muscle pain level.
Vitamin E had little effect. Statin myopathy is not due to oxidative stress so we wouldn't expect Vitamin E to help much. We would expect CoQ10 to have an effect, as statin side-effects are due predominately to a drug induced CoQ10 deficiency state, and it did.
If you take a statin, and many of my patients do (statins have a potent anti-inflammatory effect and if you have an inflamed circulation then statin therapy makes perfect sense), then please take CoQ10 along with your statin. This is only common sense. But what if you had to decide on one or the other? What if your physician forbade you to take CoQ10? (and our hospitals forbid its use) Because American physicians often behave like elected representatives ("I'm not going to vote for that bill because it was sponsored by a Democrat and I'm a Republican", and visa versa), you might be told that if you take CoQ10, you will be released from their practice and cut off from statin therapy. What would you do if you had to chose one or the other?
Statin Therapy +/- CoQ10 - Effect on Endothelial Function
Endothelial function, the ability of the endothelial cells that line our arteries to generate nitric oxide, is the most important determinate of short and long-term cardiovascular health. Nitric oxide, generated within the endothelial cells from dietary arginine (in a chemical cascade that is stimulated or enhanced by fish oil, folic acid, taurine, bioflavonoids, and antioxidants), is the chemical that provides the "teflon coating" to our arteries. Nitric oxide maintains arteries in a tonic, dilated state; nitric oxide resists plaque development and abnormal platelet aggregation. So far, all treatments (drug, nutritional, or physical, including EECP and static magnetic field therapy) that have been shown to improve short and long-term cardiac outlook have been shown to improve endothelial health. Conversely, all cardiac risk factors, conditions that increase your risk of developing coronary disease and/or increase your risk for a cardiac event or poor outcome, have been shown to compromise endothelial function. Measuring nitric oxide generation as a means of assessing endothelial health is difficult. Instead we measure the ability of an artery, any artery for that matter, to dilate in response to an intervention that will increase nitric oxide production in a healthy artery.
In this study, flow-mediated vasodilation (normal is +12-15%) was evaluated in twenty five patients with known endothelial dysfunction (baseline flow mediated vasodilation < 4.5%). They received Cervistatin (a statin agent), CoQ10, or both. Look at what happened.
Co-Q levels fell in response to statin therapy, as you would expect. Statin therapy still had a therapeutic effect - endothelial function improved, but at the price of CoQ10 depletion. Statin drugs do help you, but they also hurt you. CoQ10 monotherapy also improved endothelial function; actually it did a slightly better job then did Cervistatin. CoQ10, functioning as an antioxidant, neutralizes the free radicals that would otherwise degrade nitric oxide - thus CoQ10 improves endothelial health. Combination therapy did just fine - endothelial function improved and CoQ10 deficiency did not occur. Combination therapy makes the most sense to me, and this is how I practice, but if you had to choose one or the other, I would take the CoQ10. CoQ10 will not lower your cholesterol, but in this study, its effect on endothelial health was equivalent to that of a statin, and CoQ10 stimulates the enzymes that Mother Nature gave you, while statin therapy poisons them.
James C. Roberts MD FACC
1/01/07