A journey spanning 40 years of exciting cholesterol research is revealed in a prominent cardiologist’s latest publication.
MODERN Western medicine as practised today probably saw its genesis in the 19th century, when advances in science and other discoveries ushered in the era of more systematic analysis of disease.
However, it was not until the 20th century that the application of the scientific method to medical research began to produce important developments in healthcare, with great advances in various fields.
Today, the practice of Western medicine is rooted in the notion of evidence-based medicine, where extensive research results inform clinical decision-making in the diagnosis, investigation or management of patients.
This has seen much success, and the health scourges of earlier centuries have been significantly curtailed, especially infectious disease, to the extent that some have even been completely eradicated (e.g. smallpox).
However, the downside of this has been the rise in incidence of what many term lifestyle or non-communicable diseases.
These are diseases that come about as a result of a sedentary lifetsyle, as well as unhealthy dietary habits.
Of the many lifestyle diseases that plague modern humanity, heart disease, particularly coronary artery disease (CAD), has become the number one killer in many developed and developing countries.
Also known as atherosclerotic heart disease, coronary heart disease (CHD) or ischaemic heart disease, CAD is the most common type of heart disease and cause of heart attacks.
It is characterised by plaque building up along the inner walls of the arteries of the heart, which narrows the arteries and reduces blood flow to the heart.
According to the World Health Organisa-tion, it is, as of 2012, the most common cause of death in the world, and a major cause of hospital admissions.
It is now universally recognised that one of the most important risk factors for developing CAD is high cholesterol levels, though this recognition only came decades after the first hint of a cholesterol-coronary heart disease link in the early 1900s was discovered by a young Russian pathologist named Nikolay Anichkov.
The key breakthrough came in 1955, when a nutritional scientist at the University of Minnesota, United States, Ancel Keys, suggested that it was important to conduct large-scale clinical studies where diet and health were researched.
The clinical trial that ended speculation about the role of cholesterol as a primary cardiovascular disease risk factor was the Coronary Primary Prevention Trial (CPPT) in 1973 by the NHLBI Lipid Research Clinics. It showed that lowering blood cholesterol leads to a reduction in heart attacks.
Today, the cholesterol “controversy” has not subsided, what with claims by some that it does not cause heart disease. But that’s a story for another day.
What’s more relevant today is the experiences of Malaysian consultant cardiologist Datuk Dr Khoo Kah Lin in treating hypercholesterolaemia patients, and his recently published book, My Cholesterol Journey In Malaysia.
In the book, Dr Khoo writes: “On the whole... this book chronicles my journey when I first asked this question in the early 1970s: how do we tackle the epidemic of cholesterol and CHD in a developing country like Malaysia, where resources are limited and there are other things that seem to take priority?”
The healthcare landscape has significantly changed since the 1970s, but Malaysia is still grappling with the problem of CAD, which remains the number one killer in the country.
Dr Khoo is a past president of the Malaysian Medical Association (MMA), and is currently director of the Heart Foundation of Malaysia (known by its Malay acronym, YJM), as well as Master of the Academy of Medicine of Malaysia.
He started the Inherited Cholesterol Disorder Club (ICD) in 2001 in collaboration with the pharmaceutical company Merck, Sharpe and Dohme (MSD), and YJM.
Other than providing statins at a discounted rate for familial hypercholesterolaemia (FH) patients, the club also educates and creates awareness of FH.
The book sheds light on many aspects of Dr Khoo’s work, with the most significant being his involvement in treating Malaysians with FH.
FH is an inherited condition, where the level of low-density lipoprotein (LDL) cholesterol in the blood is higher than normal from birth.
This is a result of a defect in the gene which controls how cholesterol is handled in the body. As a result, LDL cholesterol is not broken down properly, which leads to increased levels in the bloodstream.
In most cases, the defective gene is inherited from one parent (heterozygous inheritance). If it is inherited from both parents (homozygous inheritance), the condition is much more severe.
Heterozygous familial hypercholesterolaemia affects about one in 500 people while the homozygous condition is very rare.
The most important consequence of FH is the development of heart disease at a young age, which can also lead to heart attacks at a very young age.
In his book, Dr Khoo recommends a very simple test for FH: just reach down and feel your Achilles tendon. Is it thickened? If it is, and you have an LDL-cholesterol reading of 5 mmol/l and more, then you are clinically a FH patient.
The book also delves into various aspects of Dr Khoo’s work, and documents his early years in medicine to the time he started developing an interest in lipids.
He explains the basic concepts of blood lipids, which include the structure of cholesterol, triglycerides, phospholipids and apoproteins.
He also describes coronary risk factors and its frequency peculiar to the Malaysian lifestyle – food, physical activities and cigarette smoking – as well as the various treatment options available.
The book is a reflection of a lifelong journey of service and discovery, one Dr Khoo describes as follows: “All that I achieved with my colleagues was done without money or study grants, but sheer enthusiasm. People came into my life when I needed them most, and when I reflect on this, I’m always reminded of Dorothy in the Wizard of Oz. Today, I feel so blessed that the dreams that I dared to dream at the start of my cholesterol journey really did come true.”