The Message Is Clear:

It's time for a change of heart

New Cholesterol Guidelines Suggest More Americans Are At Risk For Coronary Disease

October 07, 2001|By Elizabeth Large | Elizabeth Large,Sun Staff

A decade ago you decided to watch your cholesterol, so you avoided eggs, switched from butter to margarine and finally stopped eating much fat at all. Since then you've learned that eggs might not be as bad for you as everyone thought, margarine could be more deadly than butter, and not all fats are created equal.

You want to tear your hair out when you hear that lowering your cholesterol too far below the recommended level might not be the best thing to do. Studies have suggested a link between very low cholesterol and depression.

To make matters worse, you don't understand how there can be "good" cholesterol (HDL), which helps clear out your blood vessels, as well as "bad" cholesterol (LDL), which clogs them. You know cholesterol is a fat-like substance in your blood. How can that ever be good?

And what are triglycerides anyway?

If you weren't confused enough, the government -- specifically the National Heart, Lung and Blood Institute -- has come out with complicated new guidelines for treating cholesterol, based on a number of new studies over the past 10 years.

Many more people fall in the high risk category than under previous guidelines -- Consumer Reports estimates triple the number -- which could put millions of Americans on expensive cholesterol-lowering medicines for the rest of their lives.

"We put a lot of attention on cholesterol because it's one of the factors we can modify," says Dr. Stuart Bell, a general internist in Baltimore. "Most of us are paying attention [to the guidelines]. They've had a lot of impact, no question about it."

Who is affected

The new recommendations, like the old ones, call for lifestyle changes to lower levels of LDL and triglycerides -- another form of fat in the blood -- and elevate HDL; but they also identify three new groups at high risk for heart disease and recommend aggressive treatment for them.

People with diabetes are now considered as much at risk for cardiovascular disease as someone who has already had a heart attack. Under the old guidelines, if you were a diabetic with no history of heart disease, your target level of bad cholesterol (LDL) was less than 160 milligrams of cholesterol per deciliter of blood (mg / dL). Now it's less than 100 mg / dL, a significant difference.

"We have much better data now about who's at risk for heart disease," says Dr. Roger Blumenthal, director of preventative cardiology at Johns Hopkins.

Americans with "metabolic syndrome" are now considered high risk. This syndrome involves a group of seemingly unrelated symptoms, including a waist bigger than 40 inches for men or 35 inches for women, too-low good cholesterol (HDL) and too-high blood pressure and triglycerides.

The identification of the metabolic syndrome and how it raises the risk for coronary artery disease is one of the most important changes in the new recommendations, says Dr. Margo Denke, who was on the panel of experts that developed the guidelines, which were released this spring.

The third group is people who do poorly on the Framingham test, a heart attack risk test.

People with a high Framingham risk score, according to the guidelines, should aim for an LDL of less than 100 mg / dL, although "we don't know for sure how much benefit there is in lowering it below less than 130," says Blumenthal.

You can take this test at http: / / rover2.nhlbi.nih.gov / guidelines / cholesterol / risk_tbl.htm, or a simplified test at www.consumerreports.org. You'll need to know your cholesterol levels and blood pressure.

"Don't wait for your physician to tell you [that your cholesterol is too high]," says Dr. Michael Rubinstein, chief of cardiac wellness at Union Memorial Hospital. "Public awareness is important, understanding what the risks are and that through diet, exercise and medicine you can change."

Changing habits

Even if you thought your cholesterol levels were OK, you may now need to change your habits or even go on a cholesterol-lowering medication, according to the new recommendations. About 15 to 20 million more Americans could be considered high risk under the new guidelines.

Do the recommendations benefit the pharmaceutical companies? After all, they funded many of the studies the new guidelines are based on. Whether they do or not is almost beside the point.

The fact is that high cholesterol is something you and your health-care provider can do something about.

"I think physicians are ready to use the guidelines," says Denke. "Heart disease is the No. 1 killer of Americans, and physicians want to do something to reduce disease."

If you can't make the lifestyle changes to bring down your cholesterol, your physician can prescribe effective and usually safe drugs to do the job for you.

Apart from Baycol, which was recently taken off the market, patients have reported few side effects with cholesterol-lowering medicines.

"In reality," says Blumenthal, "95 out of 100 people tolerate [the drugs] just fine."

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