Cholesterol guidelines advise more intensive treatment

Cardiologists at Temple University Hospital are working with area primary care physicians to help educate patients who are at moderate-to-high risk for heart attack about new guidelines for lowering cholesterol.

In July 2004, the National Cholesterol Education Program’s (NCEP’s) clinical practice guidelines on cholesterol management were updated. They advise that physicians should consider new, more intensive treatment options that include setting lower target levels for LDL cholesterol and initiating cholesterol- lowering drug therapy at lower LDL thresholds.

The modifications to the NCEP’s guidelines are based upon a review of five major clinical trials of statin therapy. Those trials were conducted subsequent to the release of the ATP III cholesterol guidelines in 2001.

“Unlike previous studies, these new trials included a high number of diabetics and older patients,” says Helene Glassberg, M.D., Assistant Professor of Medicine and Director of Temple’s Preventive Cardiology and Lipid Center. “The results confirmed the benefit of lowering cholesterol in these patients. Even patients older than 65 benefited from lowering cholesterol.”

The studies confirmed the benefit of lowering cholesterol in high-risk patients to an LDL of less than 100 mg/dL.

“Until now, there were questions as to whether patients would benefit from statin therapy if they fell into what was considered a grey zone with an LDL of 100-129. Now it is clear that these patients will gain by lowering their LDL using statin therapy. And we’ve lowered their LDL goal to less than 100 mg/dL. The overall message is that lower is better.”

Patients with established heart disease, diabetes, or other vascular equivalents, who are considered to be at very high risk, should have an LDL goal of less than 70 mg/dL.

The update emphasizes the importance of lowering cholesterol in older patients as well. “Many patients and doctors questioned whether older patients, who are often taking a long list of medicines, would really benefit from cholesterol lowering medications. These studies showed that even patients older than 75 benefited from cholesterol lowering,” says Glassberg.

While the update suggests that physicians use their clinical judgment to determine whether intensive LDL-lowering therapy is called for in older patients, it states that these patients should not be excluded from LDL-lowering treatments because of age alone.

The ATP III updates advise that anyone at high- or moderately-high risk of heart attack who has lifestyle related risk factors is a candidate for therapeutic lifestyle changes.

“Lifestyle changes are a critical tool in controlling cholesterol,” says Glassberg. “Proper nutrition, regular physical activity and weight control are important tools when it comes to lowering cholesterol.”

Now that the guidelines have been updated, the challenge is to educate both physicians and patients. Glassberg is concerned that many doctors may stop medications prematurely or without good rationale, and that patients are overly concerned about the side effects of statins. “The benefits far exceed the risks. I tell my patients that statins are more than cholesterol- lowering medications. They are heart pills that have clearly shown benefit beyond lowering cholesterol," she says.

“Some very modest reductions in cholesterol have resulted in some very dramatic reductions in heart events. So, there is more to it than simply lowering cholesterol.”

A copy of the update and information on the ATP III guidelines can be found online at: http://www.nhlbi.nih.gov/guidelines/cholesterol/ upd-info_prof.htm.

For more information about Temple’s Preventive Cardiology and Lipid Center, contact Helene Glassberg, M.D. at 215-707-3347.

Cholesterol Guideline Updates At-A-Glance

• Patients considered to be at very high risk should set an LDL goal of < 70 mg/dL and statin therapy is recommended to achieve goal.
• For high-risk patients with LDLs of 100-129 mg/dL, LDL should be <100 mg/dL and statin therapy is recommended to achieve goal.
• For moderately high-risk patients, LDL should be <100mg/dL and statin therapy is recommended to achieve goal.
• In high-risk and moderately-high risk patients, therapy should achieve a 30-40 percent reduction in LDL.
• Proper nutrition, regular physical activity and weight control are critical.

http://www.health.temple.edu/tuh/