Stress-inducing numbers: Lower cholesterol guidelines don't apply to everyone

Tuesday, July 27, 2004


Did recent news of new cholesterol guidelines -- hearing the number 70 in the same breath as "cholesterol level" send your blood pressure soaring?

If so, you have lots of company. The recommendations startled many. Issued by a federal panel two weeks ago, they encourage aggressive use of drug therapy to send harmful cholesterol levels plummeting in certain patients.

Some are looking at the guidelines with bewilderment, said Richard Karas, director of preventive cardiology and the Women's Heart Center at Tufts-New England Medical Center. "A lot of people are having the attitude like, well, they're not welcome," he said.

According to experts, those concerned about cholesterol are asking lots of questions: Is it possible to go that low? Why do they keep changing the numbers? Are more drugs necessary and safe? Isn't the federal panel on the arm of pharmaceutical companies?

The answer is: Relax. Cardiovascular disease kills 34 Americans per second, so don't stress.

What some people may be failing to realize is that the new guidelines aren't aimed at most Americans. They target patients at high risk of heart attack, a number estimated at between 36 million and 40 million, according to James Cleeman, coordinator of the National Cholesterol Education Program, which set the guidelines.

And within that group, the rock-bottom recommendation for reducing LDL, or low- density lipoprotein, also known as "bad cholesterol," to 70 applies only to patients who recently had a heart attack or those with cardiovascular disease plus diabetes or multiple risk factors such as high blood pressure or continued smoking.

Those factors put them at very high risk. But even in those cases, attempting to get cholesterol that low is an option. Doctors should determine treatment on an individual basis.

The other people the panel wants aggressively treated are those at high or moderately high risk for a heart attack. The LDL goal for high risk patients -- those with coronary heart disease, hardening of the arteries, diabetes or multiple risk factors such as smoking and obesity that gives them a greater than 20 percent chance of having a heart attack in 10 years -- is less than 100.

Moderately high risk patients -- those with multiple risk factors that give them a 10 to 20 percent risk of heart attack over a decade -- should shoot for LDL levels of less than 130.

The guidelines advise people at moderate risk to aim for LDL levels under 130, and low risk below 160. The average LDL level in the United States is 127, according to the American Heart Association.

News reports focusing on the number "70" confused people. "They didn't make it as clear as they should have," said Scott Laifer, a registered dietitian and fitness trainer with offices in Hillsborough and Green Brook. "People are all of the sudden concerned when maybe they don't have to be."

He stresses, however, that it is important to know where you stand. A risk calculator is available at

To calculate risk, blood cholesterol numbers are necessary. “Not too many (people) are aware of their numbers,” Laifer said. “If they are, it is more often the total cholesterol”

 So what is cholesterol anyway? Many Americans really don’t know, according to a recent study by Merckl/Scherlng-Plough Pharmaceuticals and Mended Hearts, a nonprofit organization affiliated with the American Heart Association.

 Cholesterol is a fatty substance in the body that plays an essential role in the production of hormones and other functions. Too much of it, however, can cause buildup on artery walls, blocking blood flow.

 The higher your blood cholesterol, the greater your risk of heart disease and stroke, the numbers one and three killers, respectively, of Americans. But because high blood cholesterol has no symptoms, most people don’t know they have it.

 It is critical to get it checked every five years. More than 80 percent of those who have high cholesterol don‘t have it under control, according to the Centers for Disease Control and Prevention.

 Blood cholesterol comes from two sources: food and the body itself. Diets high in animal fat are a major cause of high LDL levels, yet more than 70 percent of Americans still eat too much of it, according to a survey sponsored by the American Institute for Cancer Research. Elevated cholesterol may be hereditary, and levels rise with age.

 But there is a good cholesterol too, known as HDL, or high-density lipoprotein. That is why is important to know what makes up your total cholesterol count. To keep the cholesterols straight, Sue Taylor, a registered dietitian with the “Open the Door to a Healthy Heart” campaign, suggests thinking of them this way: LDL is lousy and HDL is healthy.

 One way HDL protects the body is by keeping I from sticking to artery walls. If a person’s HDL level is less than 40, he is considered at risk for heart disease.

Lifestyle changes, such as switching to a diet low in saturated fat, losing weight and exercising more, can lower LDL levels and raise HDL levels. But not everyone makes them. “Some people have gotten lazy and say, ‘Oh, I’ll just take a pill,’ “Taylor said. For tips on making lifestyle changes, visit

 The federal panel, which has been keeping tabs on cholesterol research for almost 20 years, views such changes as vital for managing cholesterol. But new research indicating that drugs can radically lower LDL levels has led the panel, which is coordinated by the National Institutes of Health’s National Heart, Blood and Lung Institute, to advocate such therapy for more patients.

 People shouldn’t be frustrated that the recommendations keep changing, said Karas of Tufts-New England Medical Center that science is finding ways to save more lives. This time, the evidence comes from five major clinical trials of statin therapy conducted over the past few years.

 Statins, the name of a class of drugs that includes the brand names Lipitor, Zocor, Crestor and Pravachol are the pharmaceutical industry’s most prescribed drugs taken by more than 10 million patients. They work by cutting the production of cholesterol in the liver.

 “The effects of statins are very dramatic,” said Dr. Muhamed Saric, of the Echocardiography Lab and assistant professor of medicine at the University of Medicine and Dentistry of New Jersey.

Because statins are so effective, the panel has given doctors the go- ahead to treat more patients with the drugs at higher doses sooner.

 In addition to lowering LDL levels (and modestly raising HDL levels), statins may have an effect on other ailments, including osteoporosis, multiple sclerosis, Alzheimer’s and a number of eye diseases and cancers, giving them the buzz as wonder drugs.

 They may even be able to help children. A just-released Dutch study found that statins can safely reduce inherited high cholesterol and reverse narrowing of arteries in children.

 Some statin side effects have been reported, however, including muscle and liver damage. Bayer removed the cholesterol drug Baycol in 2001 after it was linked to some patients’ deaths and to muscle disorders. AstraZeneca’s Creator is currently under fire by a consumer watchdog group, which is petitioning the U.S. Food and Drug Administration to ban it because of the muscle side effects.

 But most doctors aren’t alarmed about statins currently available. “In principle, I don’t see that anyone has shown conclusively that any of this is detrimental,” Saric said.

 In fact, statins have been shown to have a protective effect on diabetics and people with slightly elevated cholesterol. “The bottom line is that, for any amount that you decrease cholesterol, you drop the same amount of risk,” Saric said.

 But statins, even at the highest doses allowable, can’t bring LDL levels tow enough in all patients, so a second drug is often prescribed: cholesterol blockers, like the brand name Zetia, that reduce the amount of cholesterol the body absorbs.

 “It’s not just about putting people on statins,” said Marc Cohen, chief of the Division of Cardiology at Newark Israel Medical Center. It is the whole approach to picking out the right drug or the right combination of drugs.”

 A few new drug options may soon appear on the markets. Vytorin, a pill combining the statin Zocor and the cholesterol blocker Zetia, just received FDA approval. In Britain, approval has been given to sell Zocor in a low dosage without prescription. Some patient advocates and drug companies here hope the FDA will consider approving over-the-counter statins.

 Raising HDL cholesterol shouldn’t be overlooked, either. “That’s a mistake,” Karas said. “Low HDL is an independent predictor of heart disease.”

 Beginning at age 50, low HDL cholesterol is the most potent lipid risk factor for coronary heart disease in man and women.

 Drugs that raise HDL include niacin, which should be taken in prescription form. “Off-the-shelf is unregulated,” Karas said.

 Will people blow off the advice in response to recent headlines declaring that the panel that recommended aggressive drug treatment to lower cholesterol failed to disclose some members’ ties to drug companies?

 “I certainly hope not,” said Cleeman, a panelist with no ties to pharmaceutical companies. “The recommendations are based entirely, solely, exclusively on the science,” He points out that disclosures were by most of the current panelists when the guidelines were last updated in 2001.

 Consumer groups such as the Center for Science in the Public Interest and Public Citizen’s Health Research Group complained about the lack of disclosure.

 But cardiologist don’t’ see this as an issue. “These are people of extreme repute,” Karas said. Most doctors will follow the mandate, which is endorsed by the American Heart Association and the American College of Cardiology.

 The guidelines are “like a bible” for doctors, Saric said. And the bible will probably be amended again.

 Findings of three trials currently being conducted will be re viewed during the next year, Cleeman said. Some expect that recommendations for optimal levels for LDL for certain categories of people will sink again.

 So get ahead of the news and start reducing your cholesterol now.