The Cholesterol Challenge: Just How Low Can You
December 2, 2003
By GINA KOLATA
New research and studies that are under way are leading
many heart disease experts to say they expect that the
current guidelines for lowering cholesterol may not be
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 national 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 L.D.L., 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 L.D.L. 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 L.D.L. levels dropped to about 80 while it
slowly continued in those with levels of about 110. Other
studies are asking whether lower levels of L.D.L. 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 L.D.L. lower?" he asked. "The argument is becoming
Dr. H. Bryan Brewer Jr., chief of the molecular diseases
branch at the National Heart, Lung and Blood Institute,
agreed. "Our clear projection is that lower is going to be
better," Dr. Brewer said. But that, he said, "will make the
challenge even greater." After all, if most Americans with
high cholesterol levels are not reducing them to the
current recommended levels, what good will it do to ask
them to go even lower?
Some patients say they are just not interested in taking
"There are side effects to the statin drugs," said June
Hament, 56, who lives in the New Jersey suburbs of
After years of trying "every diet I could think of to lower
cholesterol" and taking herbs and supplements, Ms. Hament
said, she has finally gotten her cholesterol down with a
low-carbohydrate diet and a weight loss of about 15 pounds.
Though she had lost weight before, her cholesterol had
never budged, she said. While it is still above the
guidelines, she is satisfied.
"Cholesterol seems to me possibly a symptom of something,
not necessarily a cause," she said.
Heart disease experts are troubled and frustrated. They
know that the guidelines, if followed, will mean a windfall
for drug companies, whose annual sales of statins, the most
popular cholesterol drugs, are about $12.5 billion a year,
according to IMS Health, which tracks drug sales. But,
experts say, cholesterol lowering can prevent much of the
misery of heart disease, and the drugs are highly effective
for those who need them. So why do so many Americans have
cholesterol levels that are so high?
"It's a very complex issue," said Dr. Gregg C. Fonarow,
professor of cardiovascular medicine at the University of
California at Los Angeles. "Entire conferences of experts
have gotten together to try to understand the paradox."
In surveys, doctors say they know the guidelines. The heart
institute's Web site (www.nhlbi.nih.gov
/guidelines/cholesterol/index.htm) 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
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.
Dr. Fonarow adds that patients often feel that taking a
drug is an admission of failure. They think they should be
able to get their cholesterol levels down with diet and
exercise and weight loss. Many are unable to do it, and
even if they did, many would never get their L.D.L. below
100 without a drug.
Dr. Scott Grundy of the University of Texas Southwestern
Medical Center, a member of the expert committee that wrote
the guidelines, said the group had debated at great length
whether to recommend trying a diet before starting drugs.
The members knew that the drugs were expensive, about $100
a month for those without prescription drug plans, and that
weight loss could provide other benefits, like reducing
blood pressure and improving diabetes. They did not want to
abandon dieting, he said, but they knew that many patients
had trouble complying and that diets often did not reduce
"We used to say try a diet first, but we realized that
wasn't working," Dr. Grundy said. "Now we say if you are at
high risk, you're supposed to start drugs simultaneously
with diet. For the others, we used to say try six months of
diet. Now we say three months; at least we give them a
Some doctors are prescribing doses that are too low, Dr.
Cleeman said. "I believe that doctors give a starting dose
of a drug and don't ratchet it up to get enough L.D.L.
lowering," he said. Many doctors and patients worry about
side effects, but the drugs are very safe, he added. One
that was more risky, Baycol, was taken off the market.
The heart institute, along with the American Heart
Association and the American College of Cardiology, wrote a
paper on statins' risks (www.nhlbi.nih.gov/guidelines
/cholesterol/statins.html) noting that the worst side
effect, severe muscle disease that can be fatal if the
drugs are not stopped, afflicts less than one patient in a
million. Other problems - muscle breakdown in one patient
in a thousand and elevated liver enzyme in about 1 percent,
may require that a person take a lower dose of the drug,
change to a statin made by another company or stop taking
the drug temporarily.
"Compared to aspirin, statins are about tenfold safer for
serious adverse events," Dr. Fonarow said.
Half of those who start taking statins stop within a year.
And most who say they are simply going to lose weight,
exercise regularly and change their diets backslide.
"Patients don't like to think of themselves as having a
condition that requires that they watch what they eat and
perhaps take medicine for the rest of their lives," said
Dr. David Waters, a professor of medicine at the University
of California at San Francisco.
"You could blame it on the patients," Dr. Waters said. "You
could blame it on the doctors. You could also blame it on
the health care system. Health care plans don't really care
if you get your cholesterol tested and treated. It's a
combination of factors."