STORY BYEditor's Note:
Earlier this summer the National Heart, Lung, Blood Institute (NHBLI) and the American Heart Association (AHA) released new guidelines for determining acceptable cholesterol levels, along with treatment recommendations. Below is an interview on the subject with cardiologist James T. Willerson, MD, president of The University of Texas Health Science Center at Houston and former editor of the journal Circulation.
Q: Do you consider the new guidelines for cholesterol levels to be strong enough?
I don't believe there is a cholesterol or LDL that is ever too low. With lipid management you want to have the lowest possible low density lipoprotein (LDL)-what we call 'bad cholesterol.' The AHA has been revising its standards and gradually the recommendations have been coming down.
James T. Willerson, MD,
president of The University of
Texas Health Science Center
at Houston.
About five years ago, the AHA assigned the LDL level at 130. Doctors taking care of patients with heart and vascular disease, including myself, have known for some time that that isn't low enough-that LDL needs to be substantially lower. We needed to push for the lowest LDL possible, one well below 100, or as low as we could go.
More recently the AHA and an article published in Circulation a few weeks ago recommended that the LDL should be approximately 70 for high-risk patients. So they have been recommending downward.
Q: Are you comfortable with these levels?
I'd like to see it beyond that for high risk patients-if I could place the LDL serum value even lower–40 to 50 milligrams per deciliter [mg/dl]–I would. Evidence is very persuasive that an LDL below 70 is better than one well above 70 in reducing the progression of vascular disease.
Q: And the guidelines for HDL?
LDL and cholesterol tell only part of the story of the risk of vascular disease. The other part is the HDL, high density lipoproteins or so-called 'good' cholesterol.
Some families have genetic abnormalities that result in very low HDLs which lead to increased risk of strokes and heart attacks. The lower limit of HDLs is
50-60mg/dl.
The fact is, just as we want the lowest possible LDL, we also want the highest possible HDL. If you could put the HDL at 150 mg/dl, you'd do so. The problem is we haven't had very effective ways of raising HDL values substantially.
All the recommended strategies of weight loss, exercise, red wine or medication raise HDL only a small amount. So if you are starting with a very low HDL, it doesn't reach anywhere near what one needs.
There are some medications in development that may prove successful in raising HDL markedly. I expect them to ultimately be added to the statin drugs, along with a good diet, in a combined way to raise HDL and lower LDL and total cholesterol.
Q: Blood pressure guidelines also were revisited last year..
Yes, beyond cholesterols there are other things that are also important in atherosclerosis and risk of heart attacks and strokes.
Regulation of blood pressure is also important and must be controlled.
Blood pressure that we accepted as being 'ok' in the past is no longer advised.
A pressure reading of 150/90 is not ok, particularly in patients with diabetes and those at high risk. One wants to have a considerably lower BP. Patients should work with their doctors to lower that like that of LDL and cholesterol. (See Thursday's story: Blood Pressure 101.)
Editor's Note: Blood pressure reclassification guidelines from the National Heart, Lung, Blood Institute are as follows:
The most important risk factor of all however is a genetic one. If you receive from your parents and their parents the wrong genes, even excellent control of cholesterols will not protect you. The genetic risk overrides everything else.
But for most people who don't have the strong genetic factor for premature heart attacks and strokes, if they control their cholesterols, don't smoke, get regular exercise, and take good care of other issues such as diabetes, they have the best chance that one could possibly have in delaying or preventing heart attacks or strokes.
We will come to a time when it is possible to identify patients with strong genetic risks that override all the other risk factors. We will be able to manipulate those genes so that they don't convey those risks. This is one of the goals of the IMM [Brown Foundation Institute of Molecular Medicine for the Prevention of Human Diseases at the UT Health Science Center at Houston.]
Q: How will the new guidelines affect medication prescriptions? The pharmaceutical industry?
In patients with very high LDLs, statin drugs are going to be required. There is a new medication called Zetia or ezetimibe, which reduces cholesterol absorption in the bowel. The statins reduce the liver's ability to make cholesterol, so the two drugs together are more potent than either one alone and can further lower cholesterol and LDL.
All of these medications will eventually come off patent and then the generics become available. But, in my experience, the generics are rarely as good as the original brand. They are less expensive and for most people, the expense is going to have to be a factor. Once they become available as generics, using a generic statin is still better than using none.
Most of the very old medications used to control cholesterol, the non-statins, are not very effective.
Q: Last question: Are there any other guidelines you'd like to see revisited?
All guidelines have to be revisited periodically. The most recent blood pressure and cholesterol guidelines will have to be revised in the next 3–4 years; that is a constant throughout our lives. And all risk factors as they relate to disease have to be revisited. There will be guidelines for genetic identification of risks, guidelines for manipulation of those genes – there will always be a need to revise guidelines.
Last Updated: 8-23-2004
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