Experts expect tougher cholesterol guidelines

New research indicates more benefit from lower levels of LDL in blood


New research and studies that are under way are leading many heart disease experts to say they expect to find that the current guidelines for lowering cholesterol may not be stringent enough.

Lower may be better, perhaps even stopping heart disease in its tracks, they say. A new study looking at the growth of plaque in arteries of heart disease patients came to that conclusion. And while medical experts are awaiting the results of studies asking if lower levels also lead to fewer heart attacks and deaths, many say they are betting that the answer will be yes.

But there is just one problem. While it has become increasingly easier and more feasible to lower cholesterol levels, most people whose levels are dangerously high either do not know it or are not doing much about it.

Recent data from the Centers for Disease Control and Prevention illustrate the problem. Sixty percent of people with high cholesterol levels did not know that they were high. Of those who knew, only 14 percent were taking a cholesterol-lowering drug and only 7 percent were getting their cholesterol within the recommended limits.

Other studies, like the Minnesota Heart Survey, a survey of more than 5,000 people taken every five years in Minneapolis and St. Paul, came to similar conclusions: Nearly 60 percent of men with high cholesterol levels were unaware of them or were untreated. Among women, the percentage was more than 67 percent.

"We have wonderful, powerful tools to normalize cholesterol and prevent heart disease," said Dr. Thomas A. Pearson, chairman of the University of Rochester's department of community and preventive medicine. "We have all the tools we need. And we're not getting the job done."

The guidelines in question recommend that levels of low density lipoproteins, or LDL, which carry cholesterol to the arteries, be below 100 for those at highest risk, below 130 for those of more moderate risk, and below 160 for others. Large clinical trials found that lowering LDL to such levels sharply decreases the risk of heart attacks.

A study sponsored by Pfizer, reported last month, indicated that lower may be better. Plaque growth stopped in heart patients whose LDL levels dropped to about 80 while it slowly continued in those with levels of about 110. Other studies are asking whether lower levels of LDL lead to fewer heart attacks.

Dr. Christie Ballantyne, director of the Center for Cardiovascular Disease Prevention at Baylor, cautioned that it was prudent for policy makers to wait for those studies to be completed. But he added that high-risk patients and their doctors might come to their own conclusions. "Why not get LDL lower?" he asked. "The argument is becoming compelling."

In surveys, doctors say they know the guidelines. The heart institute's Web site (www.nhlbi. has a program to calculate risk and appropriate cholesterol levels. Yet, said Dr. James Cleeman, the coordinator for the national cholesterol education program at the heart institute, "there is underprescribing." He said that while 13 million Americans were taking statins, at least 36 million should be.

Dr. Daniel Rader, director of the University of Pennsylvania's Preventive Cardiology and Lipid Clinic, said: "In this field, this is a huge topic of discussion. Why is it that when you poll doctors or give a talk, everyone says, `Of course I know what the guidelines are. Of course I appropriately treat my patients.'"

He blames, in part, the hurried day of the busy doctor for the disparity. Many patients balk at taking a drug, and doctors often let it go.

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