Updated Cholesterol Guidelines and You

The expert group known as the Adult Treatment Panel of the National Cholesterol Education Program has updated the guidelines used by the medical profession to determine what target level of blood fats are optimal for cardiovascular protection.   Since the last guideline release in 2001, there have been five seminal clinical research trials that have changed the paradigm sufficiently to warrant this update.   The National Institutes of Health, the American Heart Association, and the American College of Cardiology sanction these recommendations.

The fundamental message is that the lower the bad (or LDL) cholesterol, the better.   This is particularly of importance to those at highest risk of cardiovascular disease.   This includes, obviously, those who already have had a heart attack, stroke, angina or disease of the aorta and arteries.   But this also includes patients with diabetes, or with combinations of risk factors like smoking, low good (HDL) cholesterol, or uncontrolled high blood pressure.   If the LDL-cholesterol is over 100 milligrams per deciliter, efforts to get their LDL-cholesterol to 70 mg/dL or below should be initiated.   But even patients at moderate risk, defined as having a 10-year estimated coronary heart disease risk of 10-20% are to be treated if their LDL-cholesterols are greater than 130 mg/dL with a target LDL-cholesterol of less than 100 mg/dL.

The relatively bad news is that achievement of these lower target LDL-cholesterol levels is going to require the best lifestyle adherence a patient can muster, i.e., tight diet, exercise and weight control, but for most patients it will also mean the addition of cholesterol lowering medications.   The most potent and beneficial of these medications belong to the class of drugs known as statins, but other medications alone or in conjunction with statins may achieve the same goals.   Statins seem to have additional benefits, such as anti-inflammatory characteristics, that may have additive benefits but those remain conjectural at this time.

These guidelines may give the patient another leg up on the health plan formularies.   The weakest (and cheapest) statins may not get the 30-40+% lowering of LDL-cholesterol now recommended, but it will be imperative that the patient knows what that optimal LDL-cholesterol level is for that patient's risk profile.   The health plans, in order to demonstrate compliance with guideline goals, will have to seriously consider adding the more potent statins to their formularies.

Good news is that a good statin is now generic, and that even better ones will soon be as well.   And, of course, they are available from Canada.

With the predicted increase in use of statins will come increased costs and potentially increased risks of adverse effects.   Fortunately, the reality of statin use is that serious side effects are known, but uncommon, and are usually dose dependent.   This means that the extremely potent statins now available, or the combinations of statins with other non-statin cholesterol lowering agents, can often lower the LDL-cholesterol to the target range using the lowest statin doses.   This significant reduces the risk of damage to muscles or liver that rarely occur, but are associated with the highest statin doses.

The real problem is neither in the incontrovertible background science nor in the education of healthcare providers or patients about what needs to be done.   The primary impediment to the achievement of these recommendations will be in the implementation.   By that I mean that getting healthcare providers to motivate patients and prescribe not just a statin, but prescribe medications in the doses required to achieve the new targets, will be a formidable challenge.   In addition, getting the patient to adhere to therapeutic lifestyle changes and to take their medications will be perhaps even more difficult, especially since high cholesterol levels do not give a patient symptoms except when the results of the high cholesterol levels become evident.

With the older guidelines, it was estimated that 36 million Americans were eligible to be treated; yet only 12-14 million Americans actually received treatment.   It's estimated that up to 50 million Americans will now meet the criteria for treatment, making that gap even larger.

As these new guidelines become part of the treatment culture, healthcare providers will do their part.   All of you, as the patients, need to do yours.   Only then can the promise of reduced cardiovascular risk and events achievable by these updated lower target LDL-cholesterol levels be realized.