ArcaMax

DEAR DR. ROACH: Recently, I underwent breast cancer surgery at my local hospital. Imagine my surprise when I found several staff members who weren't wearing masks in the operating room. Later I learned the policy is that staff do not have to mask up until the field is sterile. In your opinion, is this good disease control management? It certainly made me feel unsafe as I went under general anesthesia. -- P.T.

ANSWER: The surgical team wears masks in the operating room to reduce the risk of the patient getting an infection. This is only part of the routine to reduce surgical infections, which also includes careful handwashing, clean garments that are only worn in the OR, and cleaning the skin with a surgical cleanser. Together, with careful surgical technique, surgical infection rates have dropped dramatically.

Certainly, the most important time to be wearing a mask is after the skin is prepped. I did read a study that didn't show a difference in surgical infections depending on mask use in the operating room. (One exception were surgeries that involved placing an implant.) Older patients are at a higher risk when the OR staff doesn't wear masks.

These studies largely came before the pandemic. Now that COVID is here to stay, it is reasonable for staff to be wearing masks around patients all the time, at least when there is COVID activity in the community. For operations with older patients and operations that involve implants, or when COVID or other respiratory viruses are active, it is particularly important for OR staff to wear masks around patients.

DEAR DR. ROACH: I am a 79-year-old male with two coronary artery stents that were placed in late 2021. I am on 20 mg of atorvastatin for cholesterol control. My last lipid panel showed an LDL level of 75 mg/dL. My clinical lab indicates that the desirable range is 0-99 mg/dL.

At my last cardiology visit, my cardiologist said he would like my LDL to be under 70 mg/dL. He told me to double the atorvastatin to 40 mg. However, taking two 20-mg pills of this prescription produced terrible gastric acidity. I get the impression that my body won't tolerate it.

Since 75 mg/dL is just about in the mid-range for the lab, I think I should continue to take 20 mg of atorvastatin once in the evening. Does this seem reasonable? Should I switch to another statin? -- W.W.

ANSWER: In my patients with known blockages in their arteries, I try to push down their LDL levels below 70 mg/dL -- and, if my patients will tolerate it, below 40 mg/dL as recommended by European guidelines. Most people can achieve this with high-dose statins. Up to 80 mg of atorvastatin is tolerated well by most people.

Stomach acid is not a common side effect of statin use; in fact, some studies have shown that statins improve reflux symptoms. However, if you aren't tolerating it, there are at least three other options.

One is to live with your LDL at 75 mg/dL as it's pretty close to 70 mg/dL, like you suggest. Alternatively, you could try another statin. Rosuvastatin is even more potent than atorvastatin and is often tolerated well even in people who have side effects with atorvastatin.

Finally, you could try a second agent in addition to your 20 mg of atorvastatin, such as ezetimibe, which works in a different way from statins and is likely to bring your cholesterol down into the goal of less than 70 mg/dL. A PCSK9 inhibitor (such as alirocumab) would very likely get you below 40 mg/dL in combination with atorvastatin. Both of these medicines have different side effects from statins.

A lower LDL means less risk of a heart attack.

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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.

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