Q: My LDL (or
”
bad
”
) cholesterol level is 126, but I read that cardiologists now
recommend a level well below 100. I can’t achieve that level
without some potent medication. Is it appropriate for me to request
medication to lower my LDL further?
Q: My LDL (or “bad”) cholesterol level is 126, but I read that cardiologists now recommend a level well below 100. I can’t achieve that level without some potent medication. Is it appropriate for me to request medication to lower my LDL further?
A: A federal panel of experts – including representatives from the American Heart Association, the American College of Cardiology and the National Institutes of Health – released a revised set of cholesterol guidelines in July 2004.
For many years, the experts have recommended targets for your “bad” LDL cholesterol, based on your risk for heart disease. If you have heart disease, or are at high risk to get heart disease, it’s more important that your LDL cholesterol level be low.
What has changed with this year’s recommendations is that the target LDL cholesterol level has been lowered for people with heart disease or at high risk for getting heart disease.
The revisions also change the point at which cholesterol-lowering medications should be prescribed. This means more people will be advised to take pills to meet LDL targets.
The new, expert recommendations are based on the results of studies of the statin drugs such as atorvastatin (Lipitor) and simvastatin (Zocor). The studies involved only people with heart disease, but many people think that the “lower is better” lessons may apply more broadly.
Two findings stand out in the latest studies. First, if LDL levels are pushed down to 60 or so with statins, the risk of heart attack and other cardiovascular events falls further than if they are pushed down to 90 or so. How much further varied with the study, but it was enough to matter. Second, although statins have been known to cause serious liver and muscle problems, side effects in these studies were relatively rare, and these were large studies involving thousands of people.
You can try to lower your cholesterol levels by changing what you eat, but studies have shown that the average person achieves only modest reductions (4 to 13 percent) through dietary changes alone.
Standard doses of statins reliably lower LDL levels by 30 to 40 percent, so the vast majority of people who need to significantly cut their LDL levels need to take a statin.
On one hand, the latest guideline revisions aren’t such a big deal. They just tweak advice directed at people in the higher cardiovascular risk groups – although, of course, there are millions of people in those groups.
On the other hand, they are important because they’re part of a larger trend. Over the past 20 years as new evidence about LDL rolls in, experts have been pushing their recommendations about the “ideal” LDL level lower and lower.
So far, the experts recommend statins only for people who have heart disease or major heart disease risk factors. But that could change. Some doctors are already saying that many more people should be taking statins, and that everyone should try to lower their LDL levels. An article in the June 2 Journal of the American College of Cardiology said we should all be shooting for LDL levels between 50 and 70. The average American LDL level is now about 130.
Meanwhile, rules are being relaxed so it may soon get much easier for people to start taking statins on their own. British health authorities have already approved Zocor for over-the-counter sale, although a pharmacist is supposed to do a risk assessment before selling the drug. Merck is planning to refile its application to the FDA to sell its other statin, lovastatin (Mevacor), over the counter in this country.
We’re not there yet, but perhaps someday there will be a consensus that nearly everyone should be using statins to lower their LDL cholesterol. If the overall LDL recommendation were to become 50 to 70, taking a statin may become part of the daily health routine.
As for now, the current recommendations are summarized in the table. If you do not know your heart disease risk factors or your LDL cholesterol level, you should talk to your doctor to see if the recommendations apply to you.
E-mail questions to the Harvard Medical School Adviser at www.health.harvard.edu/adviser.
