Report urges individualized, cholesterol-targeted approach to heart disease and stroke

A recent guideline for using statins to reduce atherosclerotic cardiovascular disease has wavered too far from the simple cholesterol goals that have saved thousands of lives in the past decade, and doesn't adequately treat patients as individuals, experts said today in a national report.

An expert panel coordinated by the National Lipid Association has created its own outline for how to best treat people at risk for cardiovascular disease, which they say focuses on reducing cholesterol to an appropriate level, and puts less emphasis on whether or not a patient fits into a certain type of group.

"We continue to believe in cholesterol targets that are easy for patients to understand and work toward, first using changes in lifestyle and then medication if necessary," said Matt Ito, one of two lead authors on the report, an expert in cardiovascular drug treatments and a professor in the Oregon State University/Oregon Health & Science University College of Pharmacy.

"We're also concerned about treating people just because they fall into a group that's supposedly at risk," Ito said. "There are ways to more accurately treat patients as individuals and understand their complete health profile. And we have a better understanding now of what conditions pose the most risk for causing a heart attack or stroke, and how to address that in a comprehensive manner."

A report issued last year by the American College of Cardiology and American Heart Association identified four general groups that would primarily benefit from statins, and its recommendations if followed will dramatically increase the number of people using these drugs.

By contrast, the new report from the National Lipid Association, published in the Journal of Clinical Lipidology, has outlined what their experts believe to be a more individualized set of recommendations that practitioners could use to treat people at risk of cardiovascular disease; more information is available online at www.lipid.org/recommendations. They are intended to complement the guidelines issued by the American College of Cardiology and the American Heart Association, Ito said.

Among the conclusions in the report:

• A root cause of atherosclerotic cardiovascular disease is cholesterol-containing particles attaching to the walls of arteries.
• A healthy lifestyle that incorporates diet, weight management and exercise should be the first approach to lowering cholesterol levels that are too high.
• Control and reduction of LDL, or "bad" cholesterol is important, but an even better overall marker of risk is "non-HDL cholesterol," which is total cholesterol minus its HDL component.
• Patients at very high risk, such as those who have already had a cardiac event, should try to achieve non-HDL cholesterol levels below 100, while those at lower risk levels should try to achieve levels below 130.
• Drug therapies specifically aimed at lowering triglyceride levels may not be necessary unless they are very high, over 500; and efforts to specifically raise HDL levels have been shown to be both less important and less achievable.
• Use of more potent statin drugs, at moderate to high doses if necessary, should be the first approach to reach cholesterol goals if lifestyle changes have not been adequate.
• Use of other medications or therapies, such as fibrates, cholesterol absorption inhibitors, niacin or omega-3 fatty acids can be considered if cholesterol and triglyceride goals are not reached with statins alone.
• Non-lipid risk factors should also be managed, such as high blood pressure, cigarette smoking and diabetes.

"Cholesterol is still a primary factor in atherosclerotic cardiovascular disease," Ito said. "If it's too high, the levels should be brought down by changes in lifestyle and medication if necessary. And in general, the lower the cholesterol, the better."

Statins have proven themselves as one of the most effective way to reduce cholesterol, Ito said, and are now comparatively inexpensive with limited side effects. Proper medication management and reducing the potential for drug interactions can address some types of side effects, and any problems should be weighed against the risk of heart attack or stroke, he said.

Factors known to raise the risk of atherosclerotic cardiovascular disease include age, family history, smoking, high blood pressure, overweight, diabetes, and high cholesterol levels, especially those caused by genetics.