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Coronary Heart Disease

From the Current Issue

How Low Should Your LDL Cholesterol Be?
New guidelines mean more people should be taking medications.

If your doctor has recently become more aggressive about lowering your low-density lipoprotein (LDL, or “bad”) cholesterol—for example, setting a lower target goal and increasing your statin dosage—it’s likely that the adjustment was inspired by new guidelines.

The guidelines call for lower LDL cholesterol levels for people at high or moderately high risk for a heart attack. They were published in the journal Circulation in 2004 and are endorsed by the American Heart Association, the American College of Cardiology, and the National Heart, Lung, and Blood Institute. An expert panel based their recommendations on five recent clinical trials showing that more aggressive lipid-lowering therapy is more effective than the current moderate therapy recommended in the 2001 U.S. National Cholesterol Education Program (NCEP) guidelines.

The Evidence

The most recent of the five trials—the Pravastatin or Atorvastatin Evaluation and Infection Therapy (PROVE-IT) study— was published in The New England Journal of Medicine in 2004. It measured the relative impact of different treatment strategies on clinical outcomes such as heart attack and death. The trial compared these strategies in more than 4,000 patients who had been hospitalized for acute coronary syndrome (a recent heart attack or unstable angina). The participants were randomly assigned to receive either standard or intensive lipid-lowering therapy.

The PROVE-IT trial reported that reducing LDL cholesterol levels below currently recommended targets clearly benefited patients with acute coronary syndrome. Standard therapy lowered LDL cholesterol levels to an average of 95 mg/dL, while intensive therapy reduced LDL cholesterol to an average of 62 mg/dL.

The benefits of high-dose statin therapy became apparent within a few months. After a follow-up of two years, patients on intensive therapy had experienced a 16% lower risk of unstable angina, heart attack, and bypass surgery than those on standard therapy. In addition, the death rate from all causes after two years was almost 30% lower in the group receiving high-dose statin therapy.

The findings and new recommendations apply only to secondary prevention—that is, preventing heart attacks and, possibly, strokes in people who already have coronary heart disease (CHD). But many experts expect that future research may show that aggressive LDL cholesterol lowering is also effective for primary prevention—that is, improving outcomes in people without known CHD.

The positive results of the PROVE-IT trial and the other four studies examined by the expert panel strongly suggest that people who’ve already had a heart attack or other cardiovascular event—who are, therefore, at high risk for future heart attacks and death—can greatly benefit from intensive lipid-lowering therapy.

Your New Goals

If you are at low risk for a heart attack, your LDL cholesterol target goal is still the same—160 mg/dL or lower. Similarly, if you are at moderate risk, your LDL cholesterol target is still 130 mg/dL, and drug treatment may be considered if LDL cholesterol levels are 160 mg/dL or more.

People at higher risk for a heart attack, however, have new goals. Those at moderately high risk may want to lower their LDL cholesterol to less than 100 mg/dL (rather than 130 mg/dL) and to start using medication when LDL cholesterol is between 100 and 129 mg/dL. People at high risk should consider lowering their LDL cholesterol to less than 70 mg/dL (the previous goal was 100 mg/dL) and to begin drug treatment even if LDL cholesterol levels are below 100 mg/dL.

What To Do

First determine how many of the following risk factors you have:

• cigarette smoking;

• high blood pressure (140/90 mm Hg or higher) or taking blood pressure-lowering medication;

• HDL cholesterol below 40 mg/dL;

• family history of a premature CHD event (under 55 in men, under 65 in women) in a first-degree relative (mother, father, or sibling); and

• older age (45 or over in men, 55 or over in women).

Next, calculate your 10-year risk of a heart attack. If you do not have access to the Internet, ask your doctor what your risk is.

Then, consult the table above to determine your LDL goal and at what LDL level you should start taking medication. According to the new guidelines, statin therapy should be intense enough to achieve at least a 30% to 40% reduction in LDL cholesterol levels. And don’t forget that lifestyle changes—such as quitting smoking, eating a healthy diet, and exercising—can help make your medication more effective.

Adapted from Circulation, July 13, 2004, p. 236.



The Heart Bulletin is a quarterly publication that presents the latest information available to help you make informed decisions about your cardiac care.
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