In 2001 public-health experts set aggressive new cholesterol guidelines that nearly tripled the number of people who should be taking cholesterol cutting drugs to almost one-fifth of all adults. Now many experts suspect that even those goals probably aren't aggressive enough.
One reason: People at high coronary risk who reduced their bad LDL cholesterol to well below the 2001 target level stopped artery clogging from g etting worse in one study and slashed their risk of heart attack and stroke in another. Moreover, research suggests that certain relatively new risk fac tors may increase many people's cardiovascu lar risk to the point where they, too, should consider sharply cutting their cholesterol levels.
That evidence suggests that many more people may need to take cholesterol-lowering drugs and that many of those already on them may need to boost the dosages, switch to a stronger drug, or try multiple medicines.
But that call for more-aggressive treatment comes when few people are meeting even the 2001 cholesterol goals. While new drugs could make reaching lower levels easier, their long-term safety remains unknown. And the uncertainty extends beyond drugs: A flurry of research, b est sellers, and other publicity has convinced many Americans that the low-fat diet recommended for reducing cholesterol l evels, with or without medication, may not be best after all.
- THE LOWER THE BETTER?
Cholesterol travels through the bloodstream as part of larger particles known as lipoproteins. Treatment for elevated cholesterol levels focuses on low-density lipoprotein (LDL), which tends to dump its cholesterol load into the artery walls. Whether and how much you need to lower your LDL level depends in part on your overall coronary risk, which is determined by your LDL plus other established risk factors such as diabetes, high blood pressure, smoking, and a family history of heart disease, according to the 2001 guidelines.
The research, while preliminary, suggests that starting cholesterol medication at less-elevated LDL levels and aiming lower than those guidelines mandate may often be worthwhile, especially for people at highest risk. A large British clinical study published in 2002 found that giving medication to high-risk people reduced their chance of heart attack or stroke by roughly 25 percent. Risk fell significantly even in those who had an initial LDL level below 100 milligrams per deciliter (mg/dl)-the guidelines' threshold for starting drug treatment in high-risk people-and who then got their LDL down to an average of 65 mg/dl. Another clinical trial, presented at the American Heart Association's annual meeting in 2003, found that arterial plaque deposits stopped expanding only in an aggressively treated group that got its average LDL level down to 79 mg/dl.
Our medical consultants say that people at high coronary risk who have an LDL level above 100 mg/dl should almost certainly start drug therapy in addition to making lifestyle changes a more aggressive approach must also be justified in people who are at moderate coronary risk based on standard risk factors but have other less established factors, too. These include elevated C, reactive protein (CRP), a marker of arterial inflammation ; elevated homocysteine, artery-damaging amino acid; and arterial calcium deposits, which correlate fairly well with ' plaque buildup. E xperts believe elevations in any of those factors may vault otherwise moder ate-risk individuals into a higher-risk group and thus justify aggressive cholesterol-cutting therapy. Again, that's a decision each person must make with his or her doctor.