Skip to comments.Experts Set a Lower Low for Cholesterol Levels
Posted on 07/12/2004 11:48:01 PM PDT by neverdem
Federal health officials yesterday sharply reduced the desired levels of harmful cholesterol for Americans who are at moderate to high risk for heart disease.
The new recommendations call for treatment with cholesterol-lowering drugs for millions of Americans who had thought their cholesterol levels were fine. Already more than 10 million people take the drugs. But now, more should start, the recommendations say. For people at the highest risk, they suggest that the target level of L.D.L., the type of cholesterol that increases the likelihood of heart disease, should be less than 100. That is 30 points lower than previously recommended.
For people at moderately high risk, lowering L.D.L. to below 100 with medication should be seriously considered, the report said. The advice for people at low risk remains unchanged.
The recommendations were published today in the journal Circulation and endorsed by the National Heart, Lung and Blood Institute; the American Heart Association; and the American College of Cardiology. The authors said the change was prompted by data from five recent clinical trials indicating that the current cholesterol goals were not aggressive enough and that more intense drug treatment led to better results.
The recommendations, which modify guidelines set by the government only two and a half years ago, will increase by a few million the number of Americans who meet the criteria for therapy with the powerful cholesterol-reducing drugs called statins, and many people who are already taking the medications will be advised to increase their doses.
Under the old guidelines, about 36 million people in this country should be taking statins, said Dr. James Cleeman, coordinator of the National Cholesterol Education Program. But only about half that number do.
In the report, the health officials addressed three questions: When are statins merely a sensible option? When are they imperative? And how aggressively should patients be treated? The recommendations focus on the levels of L.D.L., rather than total cholesterol levels, because L.D.L. is the target of cholesterol-lowering therapies.
One change applies to people at moderately high risk, defined as having risk factors like advancing age, high blood pressure or smoking that confer a 10 percent to 20 percent chance of suffering a heart attack in the next decade. Under the new recommendations, doctors now have the option of prescribing drug therapy for such patients if their level of L.D.L. cholesterol is 100 or higher, the report says, and a level of below 100 can be set as a goal.
Previously, doctors were advised to prescribe statins to moderately high risk patients only if the patients' L.D.L. levels were above 130, and the treatment was considered effective if L.D.L. levels fell below 130.
For example, following the new advice, a 57-year-old nonsmoking man who has an L.D.L. of 115 and whose blood pressure, with medication, is 130, could now receive drug treatment. Under the old rules, he would not have been treated.
The recommendations also call for more aggressive treatment of people at high risk, that is, with established heart disease, diabetes, or other conditions that give them a greater than 20 percent chance of having a heart attack in the next decade. In such cases, when L.D.L. levels are above 100, doctors should always recommend drug treatment, the report said, and no longer have the option of not prescribing the medications.
The previous advice said that drug treatment was imperative in high risk people only when their L.D.L. exceeded 130.
The report did not change the advice for people whose cholesterol levels are above 130 but who have no other risk factors. Statins are seldom prescribed in such cases.
A risk calculator is available on the heart, lung and blood institute's Web site, http://hin.nhlbi.nih.gov/atpiii/calculator.asp?usertype=prof.
Millions of Americans will be affected by the new advice, said Dr. Christie M. Ballantyne, director of the Center for Cardiovascular Protection at Baylor College of Medicine. He said that among the more than 28 million Americans at high risk, at least 8 million had L.D.L. levels of 100 to 129.
The recommendations also call for more intensive drug treatment of both moderately high and high risk patients, telling doctors that the goal should be to reduce patients' L.D.L. levels by 30 percent to 40 percent, no matter what the initial levels were.
"There is some evidence that physicians were using so-called starter doses of statins, and then not upping the dose when that did not produce enough L.D.L. lowering," Dr. Cleeman said. "We are saying, 'Don't just drop their L.D.L. a few percentage points. Drop it by 30 or 40 percent so they will get real benefit.' "
For example, Dr. Cleeman said: "If you have someone who starts at an L.D.L. level of 115, don't just give a small dose of a statin to get it to 99. Give a dose for a 30 to 40 percent reduction."
Perhaps the report's most surprising recommendation concerns the goal that doctors might set for L.D.L. levels in their patients at highest risk, those with established heart disease plus another condition like diabetes, smoking, high blood pressure or a recent heart attack. For those patients, the report said, there is a therapeutic option to drive the L.D.L. level to a breathtakingly low level - below 70.
The term, "therapeutic option," was used, Dr. Cleeman said, because while the advice was suggested by recent clinical trials, the evidence was not quite ironclad.
"The evidence is quite strong,' he said, "but it is just short of being definitive where you would say, 'Thou shalt.' "
But, Dr. Cleeman added, "I think it is reasonable to say that it is the preferred option to get these people to an L.D.L. level of less than 70."
It will not be an easy goal to achieve, heart disease experts said.
Dr. Scott M. Grundy of the University of Texas Southwestern Medical School at Dallas, the lead author of the new report, said, "A standard dose of statins gets most people close to 100.''
"If you are going to get from there down to 70, you have to take a high dose of statins," Dr. Grundy said, "which still might not get you there."
One possibility, he said, is to add another drug like niacin or ezetimibe, a drug that reduces the amount of cholesterol absorbed from the digestive tract.
But even then, said Dr. Daniel Rader, director of preventive cardiology at the University of Pennsylvania School of Medicine, many people will not be able to reach an L.D.L. level of 70. "There definitely are still going to be people who even with combination therapy can't get their L.D.L. level into that range," Dr. Rader said.
No one doubts that the new recommendations will be expensive. But, Dr. Cleeman said, statins, which cost about $100 a month, are cost effective in those who should be taking them, because heart disease costs "hundreds of billions of dollars." Statins, which can reduce the risk of heart disease by 30 percent to 40 percent, he said, "compare very favorably to other standard treatments, like treatments for hypertension."
The stock of Pfizer and Merck, two manufacturers of statin drugs, showed little change yesterday.
Heart disease researchers say they are taken aback by the speed at which the old rules are being rewritten in response to growing evidence that lower is better.
"It is really quite extraordinary," said Dr. Steven Nissen, a cardiologist at the Cleveland Clinic.
He said, "When I was in medical school, I was taught that any cholesterol level under 300 was normal."
He explained that someone with a total cholesterol level of 300 will have an L.D.L. level over 200.
"Now here we are a few decades later saying that patients at high risk should take their L.D.L. levels to 70 or less," Dr. Nissen said.
He and others, like Dr. Valentin Fuster, director of the Cardiovascular Institute at the Mount Sinai School of Medicine in New York, predict that the optimal levels for L.D.L. cholesterol will go lower still.
Clinical trials under way are expected to provide even stronger evidence of the value of intense cholesterol lowering, Dr. Fuster and others said. Dr. Fuster added that in the future even L.D.L. levels of 70 would seem too high for those at greatest risk.
"I can predict that the guidelines will be modified to be more and more aggressive, and it will happen in the next three years, if not earlier," he said.
What you said!!!
Reminds me of Brave New World and Soma - everyone got their weekly dose to keep them mellowed out. Also how babies in utero (or rather, scientific beakers or whatever) and during training were subjected to greater and lesser amounts of stuff like oxygen to promote various characteristics.
I gotta re-read "Brave New World". Huxley, although repellent in many ways, was also prescient. Actually he wasn't that bad a dude.
My total cholesterol was over 400 in June.
I've been using Zocor 10 mg. for about a month.
If I'm not mistaken, statins are already OTC in England.
Don't be surprised by a sharp increase in liver disease within five years.
Anecdotal evidence is not science. Fact is, statins are pretty much a wonder drug and there's even better ones on the horizon.
Kidney stones; renal disease; myopathies, including cardiac.
And I am not professional med staff. This is just what the averagely educated person could be aware of. Probably a lot more than all this. What about interactions between the various BP meds/sterols/statins?
Go back to your doc for a follow up visit, repeat blood test assuming liver enzymes were previously checked, and tell your doc if you have any complaints. Although rare, as previously mentioned, liver and muscle problems are the most common.
How about when secular humanism was embraced by the manipulators of the culture?
And here I thought I had problems with the discovery a few weeks ago that my cholesterol was 308.
Did you have other problems that prompted you to see the doctor and discover your high cholesterol? I went and saw my doctor because muscles throughout my body were starting to twitch uncontrollably. It was keeping me up all night and initially my doctor thought it was Benign Fasculation Syndrome but once we discovered my out-of-control cholesterol and changed my diet the fasculations went away almost immediately.
New drugs, huh?
Pharmaceutical comapnies and their investors wouldn't have anything to do with this, would they? Nah, didn't think so. </sarcasm
Wow. 308 is high too. They tested me again,
cause they couldn't believe I was over 400.
I am skinny, with a lean diet.
I have genetically high cholesterol.
Hopefully medicine will help.
I checked it after donating blood.
I'm glad thet you've recovered from the 'fasculations'!
Try some diet and excercise to lower cholesterol.
(Niacin works too!)
I was at that point 14 years ago! 10mg is the smallest dose and (if you tolerate it) your dosage will be increased substantially (in incremental amounts) before your LDL is under control.
I've been on Zocor for 14 years now (currently at 60mg/day) and my LDL bounces around 80 (would be much better if I paid much attention to my diet, but I don't)... Regular blood tests will track your progress!
The HDL/LDL ratio is important also:
For men, a ratio of 3.6 is the "average risk" level currently. A ratio of 1.0 is "1/2 average risk". Those are your goals...
Bingo, we have a winner.
Thanks for the info. I'll check my stats soon.
I've heard that oatmeal helps control cholesterol.
I wonder, does that include oatmeal stout? (and beer?) ha ha
Oatmeal... perhaps, beer, no way (I said I do not observe a "healthy diet regimen"...).
For a good overview of cholesterol as a health issue, as well as treatments, go to http://www.lef.org/protocols/prtcl-032.shtml
Statin users need Coenzyme Q10 supplementation. Merck knows this as they patented a combo product yet never moved forward with it.