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Update on Cholesterol
More Aggressive Treatment Needed for Higher
Risk Heart Patients
National Heart, Lung, and Blood Institute,
American College of Cardiology, and American Heart Association Endorse
New Cholesterol Guidelines
July 16, 2004 We have not been aggressive enough
in lowering bad cholesterol - which plagues many senior citizens - and
need to consider new, more intensive treatment for people at high and
moderately high risk for heart attack. This is the recommendation in the
2004 update to the National Cholesterol Education Programs (NCEP)
clinical practice guidelines on cholesterol management, released this
week.
NOTE: Since this story was published, it has
been challenged by consumer groups -
click here to story July 17, 04.
It also
reports new evidence supporting the idea that it is never too late for
people to benefit from intervention to lower cholesterol levels.
The treatment advice is aimed at physicians and
says options include setting lower treatment goals for LDL (bad)
cholesterol and initiating cholesterol-lowering drug therapy at lower
LDL thresholds.
The report is endorsed by the National Heart,
Lung, and Blood Institute (NHLBI), the American College of Cardiology,
and the American Heart Association. The document is based on a review of
5 major clinical trials of statin therapy** conducted since the 2001
release of the NCEPs cholesterol guidelines known as the Adult
Treatment Panel (ATP) III Report. NHLBI, a component of the National
Institutes of Health, coordinates the NCEP.
The recent trials add to the evidence that when
it comes to LDL (bad) cholesterol, lower is better for persons with high
risk for heart attack, said NHLBI Acting Director Barbara Alving, M.D.
These trials show a direct relationship between lower LDL cholesterol
levels and reduced risk for major coronary events. So, it is important
to consider more intensive treatment for people at very high risk, she
added.
Major recommendations in the update include:
*High and Very High Risk:
 For
high-risk patients, the overall goal remains an LDL level of less than
100 mg/dL. But for people at very high risk, a group that is considered
a sub-set of the high-risk category, the update offers a new
therapeutic option of treating to under 70 mg/dL. For very high-risk
patients whose LDL levels are already below 100 mg/dL, there is also an
option to use drug therapy to reach the less than 70 mg/dL goal.
For the overall category of high-risk patients, the
update lowers the threshold for drug therapy to an LDL of 100 mg/dL or
higher and recommends drug therapy for those high-risk patients whose
LDL is 100 to 129 mg/dL. In contrast, ATP III set the threshold for drug
therapy for high-risk patients at an LDL of 130 mg/dL or higher, and
made drug treatment optional for LDL 100 to 129 mg/dL.
The NCEP defines high-risk patients as those who
have coronary heart disease or disease of the blood vessels to the brain
or extremities, or diabetes, or multiple (2 or more) risk factors (e.g.,
smoking, hypertension) that give them a greater than 20 percent chance
of having a heart attack within 10 years. Very high-risk patients are
those who have cardiovascular disease together with either multiple risk
factors (especially diabetes), or severe and poorly controlled risk
factors (e.g., continued smoking), or metabolic syndrome (a
constellation of risk factors associated with obesity including high
triglycerides and low HDL). Patients hospitalized for acute coronary
syndromes such as heart attack are also at very high risk.
*Moderately High-Risk:
For moderately high-risk patients, the goal remains
an LDL under 130 mg/dL, but the update provides a therapeutic option to
set a lower LDL goal of under 100 mg/dL and to use drug therapy at LDL
levels of 100 129 mg/dL to reach this lower goal.
Moderately high-risk patients are those who have
multiple (2 or more) risk factors for coronary heart disease together
with a 10 to 20 percent risk of heart attack within 10 years.
For
high-risk or moderately high-risk patients, the
report advises that the intensity of LDL-lowering drug therapy be
sufficient to achieve at least a 30 to 40 percent reduction in LDL
levels. This can be accomplished by taking statins or by combining lower
doses of statins with other drugs (bile acid resins, nicotinic acid, or
ezetimibe) or with food products containing plant stanol/sterols.
*Lower/Moderate Risk:
The update did not revise recommendations for lower
risk persons: those with moderate risk (2 or more risk factors plus an
under 10 percent risk of a heart attack in 10 years) or those with 0 to
1 risk factor.
According to the report, the absolute benefits for
people at the lower levels of risk are less clear cut and the recent
clinical trials do not suggest a modification of treatment goals and cut
points.
The report emphasizes the importance of therapeutic
lifestyle changes (TLC --intensive use of nutrition, physical activity,
and weight control) for cholesterol management.
Lifestyle changes continue to be an essential part
of controlling cholesterol. TLC has the potential to reduce
cardiovascular risk through several mechanisms beyond LDL lowering,
said Scott Grundy, M.D., director of the Center for Human Nutrition at
the University of Texas Southwestern Medical Center at Dallas and chair
of the NCEP working group that developed the update report.
Like ATP III, the update addresses and emphasizes
cholesterol lowering in older persons (age 65 or above). High-risk older
persons with established cardiovascular disease are included in the
recommendations for intensive LDL-lowering therapy.
Although the update suggests that physicians use
their clinical judgment to determine whether intensive LDL-lowering
therapy is warranted in older persons, these people should not be
excluded from the benefits of LDL-lowering treatment just because of
age, said NCEP Coordinator James Cleeman, M.D.
A comparison of the key modifications in the update
with the ATP III recommendations follows:
ATP III: The goal for high-risk
patients is an LDL of <100 mg/dL.
Update: LDL<100 mg/dL is still an
overall goal for high-risk patients; for very high-risk patients, a
therapeutic option is to treat to <70 mg/dL.
ATP III: The threshold for
cholesterol-lowering drug treatment for high-risk patients was 130 mg/dL
or higher, and cholesterol-lowering drugs for LDL 100 129 mg/dL were
optional.
Update: The threshold for
cholesterol-lowering drug treatment is lowered to 100 mg/dL or above,
and it is recommended that patients with LDL 100 129 mg/dL receive
cholesterol-lowering drug therapy.
ATP III: For moderately high-risk
persons, the LDL treatment goal is <130 mg/dL and drug therapy is
recommended if LDL is 130 mg/dL or higher.
Update: A therapeutic option is to
set the treatment goal at LDL <100 mg/dL, and to use drug therapy if LDL
is 100 129 mg/dL to reach the goal.
ATP III: Achieving a certain
percentage lowering of LDL cholesterol was not emphasized.
Update: When LDL-lowering drug
therapy is used in high- and moderately high- risk patients, it is
advised that the intensity of therapy be sufficient to achieve at least
a 30 to 40 percent reduction in LDL levels.
ATP III: Initiate therapeutic
lifestyle changes (TLC) in patients whose LDL cholesterol numbers are
above goal levels.
Update: In addition to patients
with LDL above goal, any person at high- or moderately high-risk who has
lifestyle-related risk factors is a candidate for TLC regardless of LDL
level.
According to Dr. Cleeman, the update to the ATP III
guidelines is not the final word on LDL goals. There are three ongoing
trials in high-risk individuals, which when completed, may lead to a
broader recommendation for reaching very low LDL goals in high-risk
patients.
NOTE: The five clinical trials reviewed by the NCEP
working group were: the Heart Protection Study (HPS), the Prospective
Study of Pravastatin in the Elderly at Risk (PROSPER), the
Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack
Trial-Lipid Lowering Trial (ALLHAT-LLT), the Anglo-Scandinavian Cardiac
Outcomes Trial-Lipid Lowering Arm (ASCOT-LLA), and the Pravastatin or
Atorvastatin Evaluation and Infection-Thrombolysis in Myocardial
Infarction (PROVE IT-TIMI 22).
The update was published in the July 13 issue of
Circulation: Journal of the American Heart Association.
What Is Cholesterol
and High Blood Cholesterol?
 Too
much cholesterol (ko-LES-ter-ol) in the blood, or high blood
cholesterol, can be serious. People with high blood cholesterol have a
greater chance of getting heart disease. High blood cholesterol itself
does not cause symptoms, so many people are unaware that their
cholesterol level is too high.
What Is Cholesterol?
To understand high blood cholesterol, it is
important to know more about cholesterol.
>> Cholesterol is a waxy, fat-like substance that
is found in all cells of the body. Your body needs some cholesterol to
work the right way and makes all the cholesterol you need.
>> Cholesterol is also found in some of the foods
you eat.
>> You use cholesterol to make hormones, Vitamin D,
and substances that help you digest foods.
Blood is watery and cholesterol is fatty. Just like
oil and water, the two do not mix. So, in order to travel in the
bloodstream, cholesterol is carried in small packages called
lipoproteins (lip-o-PRO-teens). The small packages are made of fat
(lipid) on the inside and proteins on the outside. Two kinds of
lipoproteins carry cholesterol throughout your body. It is important to
have healthy levels of both:
>> LDL (low density lipoprotein) cholesterol is
sometimes called "bad" cholesterol.
High LDL cholesterol leads to a buildup of
cholesterol in arteries. The higher the LDL level in your blood, the
greater chance you have for getting heart disease.
>> HDL (high density lipoprotein) cholesterol is
sometimes called "good" cholesterol.
HDL carries cholesterol from other parts of your
body back to your liver. The liver removes the cholesterol from your
body. The higher your HDL cholesterol level, the lower your chance of
getting heart disease.
For more information on cholesterol, go to -
http://www.nhlbi.nih.gov/health/dci/Diseases/Hbc/HBC_WhatIs.html
What Is High
Blood Pressure?
High blood pressure is a blood pressure reading of
140/90 mmHg or higher. Both numbers are important.
About one in every four American adults has high
blood pressure. Once high blood pressure develops, it usually lasts a
lifetime. The good news is that it can be treated and controlled.
High blood pressure is called "the silent killer"
because it usually has no symptoms. Some people may not find out they
have it until they have trouble with their heart, brain, or kidneys.
When high blood pressure is not found and treated, it can cause:
>> The heart to get larger, which may lead to
heart failure.
>> Small bulges (aneurysms) to form in blood
vessels. Common locations are the main artery from the heart (aorta),
arteries in the brain, legs, and intestines, and the artery leading to
the spleen.
>> Blood vessels in the kidney to narrow, which may
cause
kidney failure.
>> Arteries throughout the body to "harden" faster,
especially those in the heart, brain, kidneys, and legs. This can cause
a
heart attack,
stroke,
kidney failure, or amputation of part of the leg.
>> Blood vessels in the eyes to burst or bleed,
which may cause vision changes and can result in blindness.
For more information
about high blood pressure, go to
http://www.nhlbi.nih.gov/health/dci/Diseases/Hbp/HBP_WhatIs.html
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