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More Aggressive Cholesterol Therapy Urged

New guidelines stress lipid-lowering drugs

TUESDAY, May 15 (HealthScout) -- Americans aren't getting screened adequately for heart disease, and they're not getting treated aggressively enough with drugs to lower their cholesterol.

Those are the conclusions behind new guidelines for doctors on how to control high cholesterol, a leading and highly treatable risk factor for coronary heart disease, the nation's leading killer.

The recommendations from the National Heart, Lung, and Blood Institute call on doctors to evaluate their patients' odds of heart disease with a simple point-scoring system and to assertively treat everyone above a certain threshold with cholesterol-lowering drugs such as statins. A summary of the recommendations appears in the May 16 issue of the Journal of the American Medical Association.

Called the Adult Treatment Panel III guidelines, they update recommendations made in 1993 and reflect a consensus among heart experts that failing to adequately control cholesterol can have dire consequences later in life.

Scientists have learned, for example, that men whose total cholesterol count -- a figure including both "good" and "bad" forms of the fat -- exceeds 240 milligrams per deciliter before their 40th birthday have more than triple the risk of dying from coronary heart disease compared with those whose levels are below that cutoff. And the risk of fatal cardiovascular disease for those men is two to three times higher.

Reining in high cholesterol, either through drugs or changes in diet and exercise habits, can reduce the odds of heart attack and heart-related death by roughly 25 percent, experts say. Treatment also can decrease the need for bypass surgery, angioplasty and other heart procedures, and lowers the risk of death from non-heart causes.

The new guidelines say all adults over age 20 should have a cholesterol screening every five years. Total cholesterol should add up to less than 200 milligrams per deciliter, and scores between 200 and 239 are considered borderline, says the American Heart Association.

Those whose low-density lipoprotein (LDL) -- the "bad" cholesterol that can lead to clots in the arteries that feed the heart -- tops 130 are at high risk of heart disease and should be put on statins immediately, with the goal of lowering the figure to 100. They also should be encouraged to modify their diets to cut out saturated fats and cholesterol, to lose weight and to exercise more. That not only lowers LDL cholesterol but boosts high-density lipoproteins (HDL), or the "good" form which protects by ferrying fatty molecules away from the heart.

The same routine goes for patients with two or more risk factors, like very high LDL cholesterol and high blood pressure, who are believed to have a 20 percent chance of heart disease over the next decade.

The new guidelines say people whose 10-year heart disease risk falls between 10 percent and 20 percent should get somewhat less aggressive cholesterol treatment, but enough to drive LDL cholesterol below 100.

Patients who already have heart disease should try to keep their LDL cholesterol below 100. And those hospitalized for heart trouble who have LDL levels above 130 should be put on statins before they're discharged to avoid potential treatment gaps if they don't get follow-up care.

Another important feature of the guidelines is how they handle diabetes. The previous recommendations consider the blood-sugar disorder a significant risk factor for heart disease. But "the new guidelines say if you have diabetes, you have heart disease" and should be treated, says Dr. Michael Lauer, a Cleveland Clinic cardiologist and co-author of an editorial accompanying the journal article.

The guidelines also encourage doctors to look for anomalies in other blood fats, such as triglycerides. And the report calls for parity in the way doctors treat high cholesterol in men and women, who tend to develop heart disease about 10 to 15 years later than men.

"Ten years ago, the amount of data on women was really very sparse," Lauer says. "We still do not have as much data about women as we should, but there has been a lot more evidence that the drugs and treatments don't work any differently" for the two sexes. "Therefore the guidelines recommend that they be treated pretty much the same."

Implementing the new guidelines should be easy for physicians, says Lauer.

"This goes well beyond the simple cholesterol screening, but if it's done right, it shouldn't add very much at all" to the length of an office visit, Lauer says. Calculating risks with a weighted checklist that includes age, smoking status, cholesterol count and other factors, takes only a few minutes and can be done on a computer or calculator, he says.

Doctors also should evaluate their practices to see how well they're conforming to the guidelines, Lauer says. If they're doing poorly, he says they could refer their heart patients to a special lipid clinic or use specially trained nurses to help monitor cholesterol therapy.

Dr. Gregory G. Schwartz, a heart specialist at the University of Colorado Health Sciences Center in Denver, says the new guidelines take into account the increasing use of statins since the last recommendations were published.

"Even the most ardent participant in life changes and modifications is unlikely to achieve the same degree of response that would be obtained with high doses of a statin," Schwartz says. However, he says people who combine the two therapies can increase the benefits of each.

A month's supply of the standard, 20-milligram dose of Merck's statin, Zocor, runs about $107 on drugstore.com.

What To Do

If you haven't had your cholesterol screened, ask your doctor about the test. Your total cholesterol level is a number you ought to know.

To see if there are any clinical trials involving high cholesterol, check out Veritas Medicine.

To learn more about high cholesterol and how to keep it in check, visit the American Heart Association. You can also try HeartInfo or the Mayo Clinic.

Read other HealthScout articles about high cholesterol.

SOURCES: Interviews with Michael S. Lauer, M.D., director of clinical research, department of cardiology, Cleveland Clinic Foundation, contributing editor, Journal of the American Medical Association, and Gregory G. Schwartz, M.D., Ph.D., professor of medicine, University of Colorado Health Sciences Center, Denver, Colorado Veterans Affairs Medical Center; May 16, 2001, Journal of the American Medical Association
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