CENTRAL  SOUTH  DAKOTA  MEDICAL NEWS
THE CLINICAL VIEW
By: Phillip E. Hoffsten, M.D.
7  JUNE  2001

Update on Cholesterol Guidelines

 Beginning in the 1950s, it was recognized that individuals who had high blood cholesterol had an increased risk for developing heart attacks and strokes. Over the last 50 years, that observation has been repeatedly confirmed.

It was recognized in the 1970s that high blood cholesterol values were associated with about 20% of all of the heart attacks that occur in the United States. That accounts for about 120,000 deaths per year. A counsel was organized by the federal government and became known as the National Cholesterol Education Program. The first report of this counsel was in the 1980s and since then a third report is now published in the Journal of the American Medical Association in May 2001. The following points are emphasized:

1.         A lipid profile is made up of four components including the total cholesterol which should be under 200 mg/%, the LDL cholesterol (bad cholesterol) which should be under 100 mg/% and the HDL cholesterol (good cholesterol) which should be over 35 mg/%. In fact, the higher the good cholesterol is the better with very high levels of HDL cholesterol associated with longevity. The last component of the lipid profile is the triglyceride level which is basically the calories that are eaten but not burned in the previous week. When a person is in calorie excess, the triglyceride level will be high. It is recommended that all adults age 40 and over have a lipid profile done to determine if there is a significant risk. If there is a strong family history of heart disease then individuals should have their lipid profile checked by age 30 so that corrections can be implemented at an early age.

2.         There is now a recognized "metabolic syndrome" sometimes called Syndrome X which is made up of individuals who are substantially overweight with abdominal obesity, insulin resistance, hypertension and finally the combination of an elevated triglyceride level with a low HDL cholesterol. Even if these individuals have a normal blood cholesterol and normal LDL cholesterol, they are still at substantial risk for developing vascular problems such as strokes and heart attacks. The medications needed to treat this are different than those that are used to treat high total blood cholesterol. These individuals need special dietary control, treatment with Niacin or treatment with a drug called gemfibrozil.

3.         Exercise continues to be an important part. of cholesterol control. Walking three miles per day within capability is strongly recommended.

4.         It is never too late to start treating blood lipids. In the past it was suggested that drugs did not help individuals over age 60 to prevent heart attacks and strokes. Nothing could be further from the truth. In fact, the medications prevent a proportionally larger number of strokes and heart attacks in the elderly than they do in the younger population. Checking blood cholesterol in individuals over age 60 and treating them aggressively is an important part of care.

5.         In individuals who have had a heart attack, it has now been shown that starting cholesterol-lowering medications at that time is an intense force in preventing the next heart attack. For any individual who has ever had a heart attack, bypass surgery or angina pectoris the use of a "statin" drug is strongly recommended.

6.         The statin group of drugs has now been shown to be as effective as coronary artery bypass surgery in preventing heart attacks. A study was done in which individuals were given a choice of bypass surgery or not. A group of individuals who refused bypass surgery were then treated with a substantial dose of a cholesterol-lowering "statin" drug. It turned out that the group of individuals treated with the statin drug had fewer heart attacks and recurrent problems than the group that was treated with bypass surgery.

7.         The side effect profile for the lipid-lowering drugs is dramatically low. Initially, there were concerns that there might be liver problems with these drugs. In fact, that has not come to the fore. Very few individuals have to stop the cholesterol medications because of side effects.

In summary, control of cholesterol and its resultant prevention of heart disease and strokes has been one of the great successes of medicine. To this time, the biggest failure of the National Cholesterol Education Program has been the small fraction of the population that is being treated for high blood cholesterol. All individuals are strongly urged to use their local clinics to have cholesterol checks done and then treated appropriately.