Just How Low Should Cholesterol Go?

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BEFORE, IF you were at high risk for heart disease, the goal was to get your "bad" LDL-cholesterol below 100 (milligrams per deciliter of blood). Now, because of rigorously controlled trials on tens of thousands of people that demonstrate lower is better for avoiding future heart-related problems in people at decidedly high risk, the National Heart, Lung, and Blood Institute says that a doctor has the option of trying to get such patients' LDL-cholesterol levels below 70.

Those at high risk for heart disease include people who have already suffered a cardiovascular "event" such as a heart attack, those who have diabetes, which is a major risk factor for heart disease in itself, and those who have greater than a 20 percent chance of suffering a coronary event within the next 10 years because of combined risk factors such as older age, high blood pressure, and low "good" HDL-cholesterol. (Smoking adds significantly to the 10-year risk as well.)

Some 14 million Americans alone have established heart disease, says Ernst J. Schaefer, MD, who heads the Lipid and Heart Disease Prevention Program at the Tufts University School of Medicine, with millions more who have diabetes or a 10-year risk greater than 20 percent. Yet the average LDL-cholesterol in this country is about 130, with fewer than 10 percent of people in the population achieving levels below 70. That means that many people would have to cut their LDL-cholesterol levels by half. Is it possible, even with drugs?

"What's optimal is difficult to achieve," says Dr. Schaefer, but by no means impossible. The most effective drugs, in descending order of effectiveness, he comments, are rosuvastatin (Crestor), atorvastatin (Lipitor), and simvastatin (Zocor). "Forty milligrams of Crestor a day can lower LDL by 55 percent," he says. There's also a new drug just approved, a combination of two other cholesterol-lowering drugs called Vytorin, that is said to be able to lower LDL-cholesterol by up to 60 percent.

Even so, Dr. Schaefer says, there are patients who are not going to be able to get below 70. "We're talking about levels you don't normally see in the population," he comments. Then, too, he adds, "there are a lot of patients who don't like the high doses" of drugs needed to bring down LDL-cholesterol so dramatically, and they "don't like drug combinations." In other words, there's a patient compliance issue, along with the fact that as a dose of a cholesterol-lowering drug increases, so does the risk of side effects, including muscle pains and an undesirable rise in certain liver enzymes.

People at high risk for heart disease, or who already have heart disease, should not panic if they can't get their LDL-cholesterol under 70, Dr. Schaefer says. "Seventy is not a fixed target. It's a therapeutic option." That is, there's a range of desirable LDL-cholesterol levels for people in the affected group, with the number 100 at the top of that range.

It's important to point out that no matter what dose of cholesterol-lowering drug is prescribed and no matter what the LDL-cholesterol goal, people should never abandon their lifestyle efforts to keep down their cholesterol levels. That's not pat advice. Without following a diet low in saturated fat, trans fatty acids, and cholesterol; without regular, moderately vigorous physical activity; and without loss of some excess weight, if necessary, the drugs don't have the same chance of working as well. Indeed, Dr. Schaefer says he has seen people eat their way around cholesterol-lowering drugs so that they don't accomplish what they're supposed to.

New Cholesterol Goal Option Established for People at Moderately High Risk, Too
Along with giving doctors the option of trying to decrease LDL-cholesterol in high-risk patients to less than 70 milligrams per deciliter of blood (rather than less than 100 milligrams, as was previously the designated lower end), the National Heart, Lung, and Blood Institute now says a doctor may want to aim for getting a patient at moderately high risk for heart disease to an LDL-cholesterol level of less than 100 rather than less than the previously established threshold of 130. People at moderately high risk include those with a 10 to 20 percent chance of suffering a heart disease-related event over the next 10 years (based on such things as age and blood pressure level) and at least two established risk factors for heart disease, such as a family history of premature heart disease and current cigarette smoking.

The LDL-cholesterol goal for people at low risk for heart disease remains the same as it always has been: less than 160.

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By Ernst J. Schaefer

Ernst J. Schaefer MD, Lipid and Heart Disease Program, Tufts University School of Medicine, Friedman School of Nutrition Science and Policy

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