Your Cholesterol Profile - In Depth (cont.)
What were the 2001 NCEP cholesterol treatment guidelines?
The ATP III recommended goal of LDL cholesterol lowering is tailored to a person's
heart attack risk. The expert panel recommended that patients with a higher
risk of heart attacks should be more aggressively treated so as to achieve
lower LDL cholesterol levels than patients with lower risks of heart attacks.
For example, patients with prior heart attacks (these patients are at high
risk of having a repeat heart attack) should have an LDL cholesterol goal of
< 100 mg/dl, whereas healthy subjects with no prior heart attacks and no
other risk factors should have an LDL cholesterol goal of <160mg/dl. (For a
detailed explanation of very high risk, high risk, moderate high risk, moderate
risk, and low risk patients, please see below).
Even then (in 2001), some cardiologists and cholesterol experts believed that aggressively
lowering LDL cholesterol below 80 mg/dl further decreases atherosclerosis
and heart attack rates among high risk patients. But, in order to
achieve these lower LDL cholesterol levels, moderate to high doses of a statin
drug (or drug combinations) often will be necessary on a long-term basis in
addition to lifestyle changes (please see discussion above). The safety of moderate
to high doses of statins over several decades is unknown. Therefore, based
on scientific information available at that time, the ATP III LDL cholesterol
target level of < 100mg/dl for high risk patients represents a
compromise, balancing the benefits of LDL cholesterol-lowering against the
potential side effects of long term moderate to high dose statins.
What were the findings of the large controlled trials published after 2001?
Since the publication of ATP III in 2001, five large controlled
cholesterol-lowering trials have been published. Three of these trials showed
that aggressively lowering LDL cholesterol (below 70-80 mg/dl) further decreased
the risk of heart attacks and strokes without significant increases in side
effects during the study period (usually from 3-5 years). These trials are: 1)
Heart Protection Study (HPS); 2)Anglo-Scandinavian Cardiac Outcomes Trial-Lipid
Lowering Arm (ASCOT-LLA); and 3) Pravastatin or Atorvastatin Evaluation and
Infection (PROVE IT).
The HPS trial randomly assigned more than 20,000 adults (aged 40 to 80 years)
with high heart attack risks to receive either a placebo or simvastatin (Zocor)
40 mg daily. The study found that there was an approximate 25% reduction in
heart attacks and strokes in men and women treated with simvastatin. This
reduction occurred even among patients whose LDL cholesterol was lower than 100
mg/dl at base line (before treatment), suggesting that there was a further
benefit in lowering LDL cholesterol levels below the target levels recommended
by ATP III.
The ASCOT-LLA trial randomly assigned more than 10, 000 patients with high
blood pressure to receive either a placebo or atorvastatin (Lipitor) 10 mg/day.
These patients had not suffered prior heart attacks. The study was stopped after
3.3 years (sooner than planned) because there was a convincing reduction in
heart attacks and strokes (by approximately 25%-30%) among the atorvastatin
treated patients. The average LDL cholesterol level dropped 29%, from 132 mg/dl
to 90 mg/dl in the atorvastatin treated group.
The PROVE IT trial was designed to determine whether aggressively loweringe
LDL cholesterol with a high dose, potent, statin drugs would reduce heart
attacks more than standard doses of statins. The patients involved in this study
were very high risk, having acute coronary syndromes (ACS), and thus were often
in imminent danger of experiencing heart attacks. Four thousand of these
patients were randomly assignedized to receive either a high dose (80 mg/day) of
atorvastatin (Lipitor) or a standard dose (40 mg/day) of pravastatin
(Pravachol).
As expected, the average LDL cholesterol attained with high dose atorvastatin
was 62 mg/dl, much lower than achieved with standard dose pravastatin, which was
95 mg/dl. At the end of two years, the incidence of heart attacks, strokes, and
the need for coronary artery bypass surgery were lowered by 16% in the
atorvastatin group as compared with the paravastin group. The PROVE IT study
suggests that aggressive lowering of LDL cholesterol below 70 mg/dl further
reduces heart attacks and other major coronary events (such as the need for
coronary artery bypass surgery) in patients at very high risk of heart attacks.
Next: What are the 2004 NCEP cholesterol treatment guidelines? »
- Statins - Read about statins, cholesterol lowering medications like Levacor, Zocor, Pravachol, Lipitor, Crestor, and more. Side effects, drug interactions, and patient information is also provided.
- Electrocardiogram (ECG or EKG) - Read about the Electrocardiogram (ECG, EKG) procedure used to reflect underlying heart conditions such as agnina, occurance of a prior heart attack or of an evolving heart attack, and more.
- Heart Attack - Overview on heart attack (myocardial infarction) and heart attack symptoms including jaw pain, headache, shortness of breath, nausea, vomiting, heartburn, sweating, and more.
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