Dr. Roach

Dr. Keith Roach

DEAR DR. ROACH: Would you please explain the pros and cons of general versus spinal anesthetic? I have had three bladder tumor resection operations with general anesthetic in the past two years and have suffered the consequences of anesthetic fog, which is sometimes very disturbing and inconvenient.
I am 82, and I’m worried about how much memory has been lost/misplaced. If further surgeries are required, would you recommend or insist on a spinal anesthetic? — D.G.
ANSWER: This is certainly a discussion to have with your anesthesiologist, who has far more expertise than I do in this matter. However, there are studies that show spinal anesthesia has a lower rate of post-operative effects on thinking than general anesthesia does, at least in people who, like you, were undergoing bladder procedures. A large review of all trials on confusion and delirium after surgery did not show a major difference between general anesthesia and regional anesthesia (like spinal), but there was a trend toward spinal being better.
The most important factor in choosing anesthesia is your overall safety and the type of surgery taking place. Your medical characteristics need to be taken into account. I would never “insist” on one type of surgery or anesthesia. You need to trust both your surgeon and your anesthesiologist to act in your best interest, since they have more expertise than you do.
Still, explaining to the anesthesiologist your concerns about “fog” after anesthesia can help them plan the anesthesia that is least likely to cause this problem. That may indeed be spinal or other regional anesthesia, rather than general.
DEAR DR. ROACH: I know there are studies showing that high cholesterol levels are predictors of heart disease, stroke and heart attacks. Are there studies that show lowering cholesterol with medications reduces those outcomes? — R.M.
ANSWER: Yes and no. The answer depends on how high a person’s risk is and what treatment is used to reduce the cholesterol. Before you consider medications, know that lifestyle treatments — especially diet and exercise — can have immense benefits in reducing heart disease risk, with no chance of medication side effects and with many additional benefits, including a lowered risk of many cancers. Physicians are often eager to start medicines and not eager enough to give people the information and motivation to make healthy lifestyle changes.
In someone with known coronary artery disease (the type of disease caused by atherosclerosis of the arteries to the heart, leading to blockages in the arteries and often to a heart attack), lowering the cholesterol has been shown to reduce the risk of a heart attack or stroke in many different studies.
The best data comes from studies on statin drugs, but ezetimibe (Zetia) and the PCSK-9 inhibitors (given by injection) also have proven benefit. An older class of drugs, the fibrates, are still sometimes used, but do not have the abundance of data showing effectiveness.
In people without known blockages, only those who are at high risk have been proven to have a reduced risk of heart disease and stroke. High blood pressure, very high total and LDL cholesterol levels, very low HDL levels, and a strong family history all increase risk, but a decision to use medications must take into account a person’s overall risk and the risk of these medications’ side effects. Men are at a higher risk than women (age and all other risk factors equaling out), but heart disease remains the leading cause of death in women — and women are systematically undertreated in North America.
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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.
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