How Low Must Your Cholesterol Go?
Who does -- and doesn't -- need cholesterol-lowering drugs.
But this list -- from the National Cholesterol Education Program -- is already outdated, says Laurence S. Sperling, MD, director of the Emory Heart Center risk reduction program.
"These are minimal guidelines," Sperling tells WebMD. "Right now those guidelines in clinical practice are already outdated." Shah and Schaefer agree that other risk factors should be considered:
- Insulin resistance
- Obesity or a BMI of greater than 30
- A waist size of more than 40 inches for a man and 35 inches for a woman
- Signs of early, asymptomatic heart disease
And there's also a "very high risk" category. This includes people who already have heart disease and people who have diabetes.
"So the target is getting LDL cholesterol under 160 in everyone, to less than 130 in people who have two or more risk factors or who have a 10% to 20% risk of heart disease over 10 years, and then less than 100 in very high risk people," Schaefer says.
And the more recent studies show that very aggressive treatment -- getting LDL levels down to 70 or 80 -- reduces the risk of worsening disease or death in very high-risk patients.
Sperling notes that though it's easy to say who is at very low and very high risk of heart disease, it's not a simple thing to evaluate heart disease risk in the average middle-aged person. Shah agrees.
"Some day, we will really be able to determine each individual's risk and ferret out those who do not have risk of a heart attack," Shah says. "Unfortunately, right now our crystal ball is very fuzzy."
This means too many people get treated too aggressively, Shah says.
"We tend to treat a lot of people, out of whom only a few will benefit," he notes. "When we say a person is high risk, for example, we mean someone with a 20% chance of stroke or death in 10 years. That is 2% a year. So for 100 such patients, 98 will not have a problem, but we will give then intensive treatment anyway. Unfortunately, we are not good enough at picking out those two in 100 people who really need such treatment. That is a limitation of our ability to predict heart disease. The better we get at predicting which patients will have a heart attack, the better we can use these intensive lipid-lowering therapies."