Louis Vida was a heart attack waiting to happen. The easygoing 44-year-old autoworker certainly didn't have family history on his side: His father had suffered a disabling heart attack at age 49 and later underwent two bypass procedures; his grandfather had an attack at 57. And at 6 foot and 270 pounds, Vida was carrying around so much extra weight that his knees often cried out for relief on the assembly line. But most distressing, when he went to his physician a little over a year ago his cholesterol was a frightening 299 milligrams per deciliter.

Vida's doctor immediately started him on a diet program and encouraged him to exercise more regularly. The regimen yielded rapid results: In six weeks his total cholesterol dropped 36 points. But after it leveled off in still-dangerous territory around 260, with his low-density lipoprotein at 182, his doctor decided to turn to drugs. Vida began taking one of the newest cholesterol-lowering drugs, atorvastatin calcium. A month later his total cholesterol was down to 163, his LDL had fallen to 116, and his high-density lipoprotein had climbed from 34 to 49. A delighted Vida voiced optimism about enjoying a longer and healthier life.

The odds are with him. A growing body of evidence indicates that lowering cholesterol dramatically slashes the risk of heart attack and stroke -- by 20, 30, 40 percent or more. Impressive results have been achieved whether patients rely on diet and lifestyle changes, drugs, or a combination approach.

The stakes couldn't be higher. More than half of all Americans have a reading above the recommended limits. Along with hypertension and smoking, elevated cholesterol is one of the three main risk factors for heart disease, which affects 25.6 million Americans and kills about 654,000 annually. Some experts think it's the most important member of the troika. In a recent study Finnish scientists found that people with a total cholesterol above 251 had nearly triple the risk of a heart attack as those with a reading below 193; patients over 309 increased their risk fivefold.

Many researchers believe that a total cholesterol reading is an imperfect indicator of future troubles. William Castelli, director of the Framingham Cardiovascular Institute, places more faith in the ratio between total cholesterol and HDL levels. "When it comes to tracking heart attack risk, it outpredicts everything," he says.

Others stress the need to watch patients' LDL readings. "An elevated level of LDL cholesterol is the major factor necessary for atherosclerosis," says Sidney C. Smith, Jr., director of the cardiovascular center at the University of North Carolina at Chapel Hill and former president of the American Heart Association.

In heart attack survivors or patients with cardiovascular disease, the advantages of lowering LDL levels are indisputable, says Howard N. Hodis, director of the atherosclerosis unit at the University of Southern California (USC). "This has been shown in morbidity and mortality studies, in imaging studies, by carotid wall thickness, by every measure we've looked at," he says. "There is no doubt about the benefit. Period."

Making such emphatic pronouncements is one thing: translating them into action is another. One recent study provides disturbing proof that cholesterol treatment still has a long way to go. Surveying the patients of physicians who were deemed among those most likely to prescribe cholesterol-lowering drugs, researchers with the Lipid Treatment Assessment Project found that 62 percent of patients being treated for high cholesterol had LDL reading sthat exceeded recommended targets. Worse, about 80 percent of patients with established heart disease -- those at greatest risk -- were failing to reach their suggested goals. And among African Americans, just 5 percent with coronary heart disease had LDL levels conforming to these standards. Thomas Pearson, the study leader and chair of the department of community and preventive medicine at the University of Rochester Medical Center in New York, had one word to describe the numbers: dismal. "Doctors need to be more aggressive about treating high cholesterol," he says.

Sidney Smith agrees. "We have a lot of work to do."

Treatment of high cholesterol has historically been spotty at best. That's unfortunate because the payoff can be great. Researchers estimate that every 1 percent decrease in total cholesterol a patient achieves brings about a 2 percent decrease in heart attack risk.

No one doubts that the preferred way to lower cholesterol is through diet and exercise. The question is, can lifestyle changes do enough?

They can for some people, says Castelli. He recalls one patient who came in with a total cholesterol level over 300. After only a month of increased activity and a low-fat diet, the man's reading plummeted more than 100 points. Even Castelli, a longtime advocate of healthy lifestyle changes, was surprised. "We brought him in for a second test because we thought it might be a mistake."

With such success stories in mind, the National Cholesterol Education Program (NCEP), a cooperative effort of public health and government organizations, practitioners, and private companies, developed a two-tiered set of recommendations that stress physical activity and sensible foods in the 1990s. Its Step I plan, geared to most patients, strongly resembled standard dietary guidelines for the general public. It suggested that people take in less than 300 mg of cholesterol per day, with fats accounting for no more than 30 percent of total daily calories (saturated fats 10 percent). The group's Step II diet offered a tougher regimen for patients with a high risk of heart disease, those with existing cardiac problems, or anyone who didn't get results on the Step I diet -- a daily cholesterol limit of less than 200 mg and only 7 percent of total calories from saturated fat.

Then, on May 15, 2001, the NCEP issued new clinical practice guidelines on preventing and managing high cholesterol in adults -- the first major update in nearly a decade. The new guidelines stress more aggressive treatment of high cholesterol and triglycerides, target metabolic risks for heart disease, and serve up a new set of therapeutic lifestyle changes (TLC), which put still more emphasis on nutrition, physical activity, and weight control.

In terms of metabolic risks, abdominal fat is high on the list. If you have a waist of more than 40 inches (if you're a man) or 35 inches (if you're a woman), consider making an appointment with your doctor. It's not an emergency, but under the new guidelines, that much abdominal fat puts you at higher risk for heart disease.

As for TLC guidelines, the new report recommends regular physical activity become a routine step in managing high blood cholesterol. As before, the TLC diet stresses reducing the intake of saturated fat and choesterol. The difference is that the new guidelines allow up to 25 to 35 percent of daily calories from fat, as long as saturated fats and trans fatty acids are kept low. (Some patients with high triglycerides or a low HDL may need more fat to keep their triglycerides and HDL from getting worse.) The new guidelines also encourage people to eat foods rich in soluble fiber, including cereal grains, beans, peas, and many fruits and vegetables.

In July 2004, the NCEP issued the latest update to its cholesterol guidelines. The update incorporated information from five major clinical trials involving statin therapy that concluded after the NCEP issued its TLC recommendations. Not only did this latest update validate previous treatment guidelines, it also advised doctors to approach treatment of high cholesterol more aggressively for those with a moderately high or high risk of heart attack. The new report counsels doctors of patients at risk to set lower treatment goals for LDL cholesterol and to start drug therapy at lower LDL thresholds.

A 1998 study confirms the effectiveness of a diet low in saturated fats and cholesterol. A team led by Henry N. Ginsberg, director of the Irving Center for Clinical Research at the Columbia University College of Physicians and Surgeons in New York, reported that subjects who spent eight weeks on the Step I diet lowered their cholesterol by 5 percent. Those who stuck to the Step II diet for the same duration saw a 9 percent drop. The results appeared consistent for a broad cross-section of people, says Ginsberg. "It didn't matter if they were black or white, a man or a woman."

Other studies have yielded even more striking evidence that many people don't need pills to bring their cholesterol down. Consider the results posted by Finnish researchers about a 20-year community intervention in the eastern part of their Baltic nation. Scientists at the National Public Health Institute in Helsinki sought to gauge how these levels and the incidence of heart disease could be diminished through a campaign that stressed health education and promoted foods low in saturated fat. Between 1972 and 1992 the study tracked nearly 28,000 men and women aged 30 to 59. Put simply, the intervention worked: During that span cholesterol levels fell 13 percent among men and 18 percent among women. More impressive, heart attack death rates fell by larger percentages.

Nothing against the Finns, but some experts questions whether a similar campaign would work in the United States. For one thing, Americans haven't been very successful at sticking to healthy diets. In dietary studies for blood pressure reduction of people in their 30s to early 50s, for example, only 50 to 60 percent are typically able to stay on track for six months, according to Paul Whelton, interim dean at the Tulane School of Medicine. "By the end of three years, the number is down to 20 percent," he says. (Whelton notes, however, that older patients are much better dieters over the long haul.)

Yet the problem sometimes has little to do with willpower. Some people, like Louis Vida, can't seem to get their cholesterol down to healthy targets through diet and exercise alone. In other cases a change in eating habits just isn't necessary. "Twenty to 30 years ago, Americans had a very high-fat diet," says Basil M. Rifkind, a senior scientific advisor at the National Heart, Blood, and Lung Institute. "Now fat intake is lower to begin with, so when somebody switches to a cholesterol-reduction diet, the results are less impressive."

What's the bottom line? According to Castelli, a good diet and activity program will help almost everyone -- whether it lowers their cholesterol to healthy levels, reduces their need for drugs, or makes them feel better. But he also admits that it's often not enough. "Sure I'm concerned about why people continue to eat high-risk foods and not exercise enough," he says. "But I'm more concerned about them dying. If two tablets can change someone's destiny, we need to consider it."

Part II: Drugs that may save your life

References

First published May 21, 2001
Last updated October 29, 2007
Copyright © 2001 Consumer Health Interactive