How Low Must Your Cholesterol Go?
Who does -- and doesn't -- need cholesterol-lowering drugs.
"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."
In the meantime, Shah says, it's important to look beyond risk factors for physical signs of disease. Cholesterol Lowering Drugs -- Not the Whole Answer
Americans spend more money on cholesterol lowering drugs -- known as statins -- than any other kind of medicine. The market is growing. And it will get larger, now that new drugs that increase HDL cholesterol are making their way through clinical trials.
These drugs save lives. But they aren't the only way to lower cholesterol. Getting more exercise, eating a low-fat/reduced-calorie diet, substituting plant-sterol products for fat, eating more soy, and getting plenty of fiber all reduce cholesterol. Add them all up, and the effect is similar to that seen with cholesterol-lowering drugs -- without the side effects or high cost.
And drugs can never be the answer to America's heart disease epidemic, Sperling notes.
"If we put statins in the drinking water, would it help public health? Yes, but public health endeavors would help more. Our obesity epidemic needs to be conquered not with medicine but with effective change for the whole population. If you're looking at cost-effectiveness, the time to teach people to eat right and exercise is when they are kids. We can do that -- or we can start throwing 10 medicines at them when they are 40 or 50 years old."