Experts Set a Lower Low for Cholesterol Levels

Federal health officials yesterday sharply reduced the desired levels of harmful cholesterol for Americans who are at moderate to high risk for heart disease.

The new recommendations call for treatment with cholesterol-lowering drugs for millions of Americans who had thought their cholesterol levels were fine. Already more than 10 million people take the drugs. But now, more should start, the recommendations say. For people at the highest risk, they suggest that the target level of L.D.L., the type of cholesterol that increases the likelihood of heart disease, should be less than 100. That is 30 points lower than previously recommended.

For people at moderately high risk, lowering L.D.L. to below 100 with medication should be seriously considered, the report said. The advice for people at low risk remains unchanged.

The recommendations were published today in the journal Circulation and endorsed by the National Heart, Lung and Blood Institute, the American Heart Association, and the American College of Cardiology. The authors said the change was prompted by data from five recent clinical trials indicating that the current cholesterol goals were not aggressive enough and that more intense drug treatment led to better results.

The recommendations, which modify guidelines set by the government only two and a half years ago, will increase by a few million the number of Americans who meet the criteria for therapy with the powerful cholesterol-reducing drugs called statins, and many people who are already taking the medications will be advised to increase their doses.

KevinMD has a short post on this subject – New cholesterol guidelines – which links to the actual guidelines.

So why have the guideline writers changed their recommendations? Simply, new studies have provided evidence that more lowering does more good.

The key feature of these new guidelines lies in the more aggressive goals for lowering LDL cholesterol in high risk patients. Instead of a goal of 100, we now shoot for 70.

The recommendations also call for more aggressive treatment of people at high risk, that is, with established heart disease, diabetes, or other conditions that give them a greater than 20 percent chance of having a heart attack in the next decade. In such cases, when L.D.L. levels are above 100, doctors should always recommend drug treatment, the report said, and no longer have the option of not prescribing the medications.

These recommendations do not have a major impact on otherwise healthy adults. As is appropriate, these guidelines focus on secondary prevention – how to prevent future injury to patients who either have diagnosed coronary artery disease or such a high likelihood (like adult onset diabetes mellitus) that we can virtually assume existing, undiagnosed coronary artery disease.

We discussed these guidelines on rounds today, and all agreed that they made sense given recent data. We then looked up the cost of atorvastatin (Lipitor) and noted that they have price the 20mg, 40mg and 80mg tablets virtually identically. Thus, we can give 80mg of Lipitor for the same cost as 20 mg per day – approximately $3.40 a day. While I am not a smoker, I believe this cost is not significantly different from the cost of a pack of cigarettes each day.

Related posts:

1. Maybe lowering cholesterol does not matter
2. More on the new cholesterol guidelines
3. No heart disease – no aspirin
4. Defining the proper guidelines – the case of cholesterol targets
5. The new cholesterol lowering drug

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