Update on Cholesterol Guidelines

DOCTOR'S VIEW ARCHIVE

The Guidelines on Cholesterol for Adults

Medical Author: Frederick Hecht, M.D.
Medical Editor: Barbara K. Hecht, Ph.D.

A 2004 update to the National Cholesterol Education Program's clinical practice guidelines on cholesterol management advised physicians to consider new, more intensive treatment options for people at high and moderately high risk for a heart attack. These options include setting lower treatment goals for "bad" LDL cholesterol and initiating cholesterol-lowering drug therapy at lower LDL thresholds. Major recommendations in the update include:

• High and Very High Risk People: For high-risk patients, the overall goal remains an LDL level of less than 100 mg/dL. But for very high-risk patients whose LDL levels are already below 100 mg/dL, there is also an option to use drug therapy to go below 70 mg/dL goal.

High-risk people are those who have coronary heart disease or disease of the blood vessels to the brain or extremities, or diabetes, or multiple (2 or more) risk factors (e.g., smoking, hypertension) that give them a greater than 20 percent chance of having a heart attack within 10 years.

Very high-risk people are those who have cardiovascular disease together with either multiple risk factors (especially diabetes), or severe and poorly controlled risk factors (such as continued smoking), or metabolic syndrome (a constellation of risk factors associated with obesity including high triglycerides and low HDL). Patients hospitalized for acute coronary syndromes such as heart attack are also at very high risk.

• Moderately High-Risk People: For moderately high-risk patients, the goal remains an LDL under 130 mg/dL, but there is a therapeutic option to set a lower LDL goal of under 100 mg/dL and to use drug therapy at LDL levels of 100 - 129 mg/dL to reach this lower goal.

Moderately high-risk patients are those who have multiple (2 or more) risk factors for coronary heart disease together with a 10 to 20 percent risk of heart attack within 10 years.

For high-risk or moderately high-risk patients, the report advises that the intensity of LDL-lowering drug therapy be sufficient to achieve at least a 30 to 40 percent reduction in LDL levels. This can be accomplished by taking statins or by combining lower doses of statins with other drugs (bile acid resins, nicotinic acid, or ezetimibe) or with food products containing plant stanol/sterols.

• Lower/Moderate Risk People: The update did not revise recommendations for lower risk persons: those with moderate risk (2 or more risk factors plus an under 10 percent risk of a heart attack in 10 years) or those with 0 to 1 risk factor.

According to the report, the absolute benefits for people at the lower levels of risk are less clear cut and the recent clinical trials do not suggest a modification of treatment goals and cut points.

Lifestyle changes (good nutrition, physical activity, and weight control) continue to be very important in cholesterol management. Lifestyle changes also have the potential to reduce cardiovascular risks through several mechanisms beyond the lowering of LDL cholesterol.