New Guidelines Emphasize Aggressive Measures to Lower Cholesterol in Millions of Americans (dateline May 21, 2001)

New U.S. government guidelines recommend a more aggressive approach for treating high cholesterol and preventing heart disease in millions of women and men. In addition to more emphasis on low-fat diets and exercise, the guidelines call for an increase in the number of people that need to take cholesterol-lowering drugs from 13 million Americans to an estimated 36 million. According to the National Heart, Lung, and Blood Institute (NHBLI), if the new guidelines are followed, the incidence of heart disease could be reduced by as much as 30% to 40%.

"Americans at high risk for a heart attack are too often not identified and, so, don’t receive sufficiently aggressive treatment," said NHBLI Director Dr. Claude Lenfant in an NHBLI news release. "Yet, studies show conclusively that lowering the level of low-density lipoprotein, or LDL, the ‘bad cholesterol,’ can reduce the short-term risk for heart disease by as much as 40%. Treatment may lower risk over the long-term—that beyond 10 years—even more. That’s why, while the intensity of treatment in ATPIII [the new guidelines] is stepped up, its primary aim remains squarely on lowering LDL [cholesterol]," said Dr. Lenfant.

The new guidelines were made by a national panel of 27 members and consultants representing public health organizations, medical groups, nursing associations, consumer groups, and federal agencies. The panel made significant updates to the previous cholesterol guidelines, which were issued in 1993. The new cholesterol guidelines include:

• Treating patients with at least a 20% risk having a heart attack in 10 years as aggressively as those who already have heart disease: Physicians should take into account a variety of factors, such as age, cholesterol, blood pressure, smoking, etc., and determine the patient’s risk of having a heart attack. Those at 20% or higher risk of having a heart attack within the next 10 years should be treated aggressively with lifestyle changes and medicines.

• Treating high cholesterol more aggressively in people with diabetes: Studies show that people with Type II (adult onset) diabetes are at high risk of dying from a heart attack. These patients should be treated as aggressively as patients who already have heart disease with dietary changes, exercise, and cholesterol-lowering medicines.

• Using a lipoprotein profile as the first test for high cholesterol: A lipoprotein profile involves measuring:
1. LDL ("bad") cholesterol
2. total cholesterol
3. HDL ("good") cholesterol
4. triglycerides (chemical form of fat in the body).

Previous recommendations only involved measuring total cholesterol and HDL ("good") cholesterol. A lipoprotein profile should be given to patients once every five years.

• Modifying the current HDL ("good") cholesterol level guideline to 40 mg/dL: The new guidelines now set the definition of low HDL ("good") cholesterol at 40 mg/dL. This level is higher than the previous definition of 35 mg/dL. This means that many more Americans have low HDL cholesterol levels that put them at higher risk of heart attacks than previously thought. An HDL level of 60 mg/dL or above is considered protective against heart disease, according to the panel.

• Emphasizing the need for nutrition, exercise, and weight control in treating high cholesterol: The new dietary guidelines recommend an intake of less than 7% of daily calories from saturated fat and less than 200 mg of dietary cholesterol. Up to 35% of daily calories can come from total fat, provided that most of these calories are from unsaturated fats that do not raise cholesterol levels. The panel recommended:
1. Greater intake of plant stanols and sterols (included in certain margarines and salad dressings) as a percentage of total daily food intake
2. Greater intake of soluble fiber (included in cereal grains, beans, peas, legumes, and many fruits and vegetables)
3. Greater need for weight control
4. Greater need for increased physical activity

• Identifying people with "metabolic syndrome" and treating them aggressively to prevent heart attacks: Metabolic syndrome is a condition characterized by abdominal obesity, high triglycerides, high blood pressure, high blood-sugar levels, and low HDL ("good") cholesterol. These people are a high risk of heart attack and should be treated aggressively with lifestyle changes.

• Treating people with high triglyceride levels more aggressively: People with high triglyercide levels (chemical form of fat in the body) are at a high risk of heart disease. Therefore, the panel recommended that even patients with borderline-high triglyeride levels be treated with weight control and exercise. Cholesterol-lowering medicines are appropriate for some people with high triglyercides.

• Advising against taking hormone replacement therapy (HRT) instead of cholesterol-lowering drugs to lower cholesterol: Because studies have not conclusively proven that HRT can decrease the risk of heart attack or death among post-menopausal women with heart disease, the guidelines recommend that women use cholesterol-lowering drugs instead of HRT for the purpose of lowering their cholesterol.

"The new guidelines will help doctors determine heart attack risk more precisely than was possible before," said Dr. Scott Grundy, ATP III chairperson and director of the Center for Human Nutrition at the University of Texas Southwestern Medical Center at Dallas, in an NHLBI news release. "That allows treatment to be more individualized. We now know that cholesterol-lowering treatment is more effective when its intensity closely matches the level of risk."

If followed, the new guidelines would increase the number of Americans currently on cholesterol-lowering diets from 52 million to 65 million. The number of people on cholesterol-lowering drugs would also increase from 13 million to 36 million. While cholesterol-lowering drugs (mainly a group of drugs called statins) can be expensive, the panel of experts overwhelmingly agreed that the benefits of lowering cholesterol and decreasing the risk of heart disease are well worth the cost of the drugs.

Examples of statins used to lower cholesterol:

• Lipitor (generic name, atorvastatin)
• Mevacor (generic name, lovastatin)
• Pravachol (generic name, pravastatin)
• Baycol (generic name, cerivastatin) *see editor's note
• Zocor (generic name, simvastatin)

Heart disease is the leading cause of death among both men and women in the United States and in Europe. Approximately 12.8 million Americans suffer from coronary artery disease and nearly 500,000 Americans die from heart attacks caused by coronary artery disease each year. Over 12 million Americans have a history of heart attack, chest pain (angina), or both. Dr. Lenfant, Director of the NHLBI, said that if the new cholesterol guidelines are followed, heart disease would no longer be the number one cause of death.

*Editor's note:
Baycol was taken off of the U.S. market on August 8, 2001 after the drug was linked to potentially fatal muscle deterioration.

Additional Resources and References

• Imaginis maintains a comprehensive section that provides information on all aspects of heart disease at http://www.imaginis.com/heart-disease/
• The National Heart, Lung, and Blood Institute (NHLBI), in conjunction with the National Institutes of Health (NIH), published a news release entitled, "NCEP Issues Major New Cholesterol Guidelines." The news release is available at http://www.nhlbi.nih.gov/new/press/01-05-15.htm
• The National Heart, Lung, and Blood Institute (NHLBI) provides information on the new cholesterol guidelines for patients, professionals, and media at http://www.nhlbi.nih.gov/guidelines/cholesterol/
• The report by Gina Kolata, "U.S. Panel Supports Widespread Use of Cholesterol Drugs," was published in the May 16, 2001 issue of The New York Times, http://www.nyt.com/