Dr Khush Mark

[Pebble]

So does that mean you accept the evidence that hypercholesterolaemia is a cause of atheroma, which is the most frequent predispoing factor in coronary disease?

[Mukkinese]

I'm sorry if my crappy communication skills are confusing, but I thought I have been quite clear and plain in my language.

I'll give it another go; Elevated cholesterol may be a factor, when combined with other factors, in a cause of heart disease.

This does not make it a cause in itself, but rather it is a risk factor in the development of heart disease.

If there were no other factors involved, then it would clearly be a cause. As we have seen, it does not follow that having elevated cholesterol will necessarily lead to heart disease. This points to the fact that there must be other factors involved.

[Pebble]

Nothing wrong with your communication skills. However, there are enough deniers out there that do not need oxygen. Considerable harm is caused by very precise statements that fail to also address the known connections between cholesterol, atheroma and coronary event rate. Those making the initial statements, such as you have, rarely would agree with how their words are used to create confusion and doubt.

This is why I keep coming back to the undeniable consequences of elevated cholesterol, and proven benefits of treatment. Once that context is kept in focus, I have no problem with exploring the deficiencies continuing to exist in our total body of knowledge.

[Matt]

We get some strange visitors here. I must have become somewhat jaded toward them. So when read:

I'm not going to defend Dr. Khush Mark or Callyourselfasceptic,

I automatically brisled with anticipation at someone who was about to defend Dr. Khush Mark or Callyourselfasceptic. T'was a pleasant surprise to find that I was wrong.

[Mukkinese]

I have no problem in saying that elevated cholesterol increases the risk heart disease. Fair enough?

[Pebble]

I have no problem in saying that elevated cholesterol increases the risk heart disease. Fair enough?

Agreed! and your position in respect of the relationship between cholesterol and atheroma?

[Mukkinese]

I don't understand your point?

If you want you can replace "heart diseases" in my last post with cardiovascular diseases, if that is any help?

[Pebble]

I don't understand your point?

If you want you can replace "heart diseases" in my last post with cardiovascular diseases, if that is any help?

No. Atheroma is not a disease as such, simply fat and inflammatory material build up in the arteries wall. However, it can reach such severity as to cause angina, intermittent claudication and cerebral hypoperfusion. This is uncommon, since more usually plaque rupture leads to a thrombotic component to it's progression, causing much more abrupt changes in degree of vascular occlusion, leading to symptoms.
As such neither atheroma nor thrombosis cause disease, generally, both are 'risk' factors. The causative nature of the relationship between cholesterol and atheroma being subject to minimal modifying factors, might I thought tempt you off the fence.

[Mukkinese]

Sorry, no.

[Pebble]

Sorry, no.

Evidence base?

[Mukkinese]

Nothing has changed from my previous argument.

There is no need for complexity, this is a simple point of logic.

If everyone who has elevated cholesterol does not develop cardiovascular disease, then there must be other factors involved. Therefore elevated cholesterol cannot be the cause, but merely one factor of a cause.

Having one or more factors, that may contribute to a cause of disease, increases the risk; hence risk factors.

To make things clear, can you tell some reasons why everyone who has elevated cholesterol does not develop cardiovascular disease?

[Pebble]

Nothing has changed from my previous argument.

There is no need for complexity, this is a simple point of logic.

If everyone who has elevated cholesterol does not develop cardiovascular disease, then there must be other factors involved. Therefore elevated cholesterol cannot be the cause, but merely one factor of a cause.

Having one or more factors, that may contribute to a cause of disease, increases the risk; hence risk factors.

To make things clear, can you tell some reasons why everyone who has elevated cholesterol does not develop cardiovascular disease?

With rare exceptions the necessary but not sufficient abnomality underpinning common cardiovascular diseases such as angina, infarction, stroke, aortic aneurysm and peripheral vascular disease is atheroma. Development of symptomatic disease, is usually precipitated by inflammation of the plaque combined with a prothrombotic state. Thus the severity of the stenoses and the rapidity of vascular occlusion are more common where there is active inflammation and dominance of the prothrombotic systems over the fibrinolytic systems.
Gradual vessle occlusion is often compensated for by the development of collaterals (or new blood supply) thus leading to asymptomatic vessel occlusion without obvious complaints.

Atheroma is driven by LDL cholesterol (evident even in 20 year olds), the rate of progression is dependent on modifying factors - endothelial damage e.g. by cigarette smoke, diabetes, high blood pressure. Thus some people develop alot of atheroma and others relatively little.

An independent process is plaque activity, driven by the inflammatory response to LDL within the plaque, again inflammation is modified by hypoxia, shear stress, metabolic syndrome etc. This also influences rate of progression, but this is a more abrupt process, tending to lead to major relatively acute changes in plaque size - therefore more strongly associated with symptoms.

Finally people with quiescent thrombotic systems, may not occlude a vessel when a plaque is inflammed or ruptured, where as this may follow rapidly in those who are prothrombotic (many conditions, including stress levels).

So the point is that atheroma has a strong relationship (causative) with LDL cholesterol (HDL having the directly opposite effect), but other factors need to come into play before you get disease. As such where you have protective factors (wine, mediterranian diet - anti-inflammatory), then there is no dicotomy between LDL and atheroma, but is a slight dicotomy in terms of rates of disease.

[Matt]

Nothing has changed from my previous argument.

There is no need for complexity, this is a simple point of logic.

If everyone who has elevated cholesterol does not develop cardiovascular disease, then there must be other factors involved. Therefore elevated cholesterol cannot be the cause, but merely one factor of a cause.

Having one or more factors, that may contribute to a cause of disease, increases the risk; hence risk factors.

To make things clear, can you tell some reasons why everyone who has elevated cholesterol does not develop cardiovascular disease?

Amazingly not everybody who is shot in the head dies. I guess by a similar logical process you could argue that those who do die after being shot in the head have other contributory causes of death.

[Mukkinese]

Pebbles; so there are other factors?

I completely understand that you, along with most healthcare professionals, may believe the other factors to be inconsequential, but clearly they are not, or else everyone who had high cholesterol would develop heart disease.

What is the ratio between all those who have elevated cholesterol and those who go on to develop cardiovascular disease?

Matt; Perhaps aim might be a factor, or the part of the brain the bullet passes through, or whether the bullet bounces around the inside of the skull, or how close the gun is to the head, the amount of damage caused etc. Certainly, being shot in the head would seem to be a very high risk factor for death, but clearly, as you say, not the only factor or else everytime would result in death.

I don't know the stats on survival of gunshot wounds to the head, but are you saying that both cases have the same probability?

Further we should not confuse, often necessary, communication short-hand for the whole of the facts.

Would a pathologist report "he died of a gunshot wound to the head" or would he detail the damage which lead to death? If the victim did not die, then many may be interested in what factors helped him survive? If you were training medics who treated gunshot wounds, or someone who designed military helmets, wouldn't you want to know?

Once we say, this or that is the proven cause for such and such, then we begin to cut off the possibility of other factors being seen as worthwhile avenues of investigation. That is my whole point.

[Pebble]

Pebbles; so there are other factors?

I completely understand that you, along with most healthcare professionals, may believe the other factors to be inconsequential, but clearly they are not, or else everyone who had high cholesterol would develop heart disease.

I have said nothing of the kind. What I have illustrated is the fact that there are other factors that modify risk, does not detract from the argument on causation, simply makes it more complex.

What is the ratio between all those who have elevated cholesterol and those who go on to develop cardiovascular disease?

The easiest way for yo to understand this is using the Cardiovascular risk prediction program, you can hold other factors constant, and explore the independent impact of varying cholesterol.

http://www.patient.co.uk/doctor/Prim...Calculator.htm