New Advice for a Healthy Heart
For: A Cluster
of Problems—and Solutions, April 2003
We reported in February on the growing popularity of cholesterol-lowering
"statin" drugs, which many healthy people take to prevent heart
disease. Among the most widely prescribed drugs in the world, statins
will surely be even more popular now that an important government-sponsored
panel of heart disease experts has announced aggressive new recommendations
for treating high blood cholesterol. If everyone followed the guidelines,
it's estimated that 65 million Americans would change their diet and make
other life-style changes, up from 50 million under the old guidelines,
and as many as 36 million would take cholesterol-lowering drugs, compared
to the current 13 million. Recent studies show that such preventive treatment
could substantially cut the number of deaths from heart disease, the No.1
killer in this country.
Under the new guidelines, many more Americans are considered
to be at high risk for a heart attack than before, and are thus candidates
for cholesterol-lowering life-style changes and possibly drug therapy.
Now more than ever, you really need to work with
your doctor to evaluate your level of risk. Even if you have previously
had your blood cholesterol measured and discussed your heart health with
your doctor, the new guidelines mean that you'll need re-evaluation.
Here are some of the main changes in testing and treatment
that may affect you:
• First, everyone age 20 or older should have a complete blood cholesterol test, called a "lipid panel" or "lipoprotein profile," which, unlike the simpler screening test, requires a 12-hour fast. This measures total cholesterol, as well as LDL ("bad") and HDL ("good") cholesterol and triglycerides (fats in the blood). You also need to know your blood pressure.
• While the guidelines for total cholesterol haven't changed (below 200 is "desirable," 240 and above is "high"), those for LDL and HDL have. Desirable LDL levels (now called "optimal" or "near optimal") are still less than 130, unless you're at high risk for a heart attack (see below), in which case the new goal is a very low 100. In the past only those who already had heart disease needed to aim for this stringent target. For most people, this requires medication. The minimum for HDL has been raised to 40, up from 35. HDL below 40 is considered a coronary risk factor.
• The risk factors for heart disease are mostly the same, notably age, smoking, high total and/or LDL cholesterol, low HDL, high blood pressure, family history of premature heart disease, and obesity. These factors are even more important now in determining how aggressively your elevated cholesterol will be treated.
• Diabetes is now singled out as so potent a risk factor for heart disease that by itself it puts you in the highest-risk category, along with people who already have heart disease. So everyone aged 45 and over should be tested for diabetes. And people with diabetes now need to get their LDL below 100, which usually requires drug therapy.
• One new risk factor is called "metabolic syndrome," which is largely related to obesity and inactivity. You qualify if you have three or more of the following: abdominal obesity (a waist more than 40 inches for a man, 35 for a woman); low HDL (below 40 for a man, 50 for a woman); fasting triglycerides of 150 or more; elevated blood pressure; and fasting glucose of 110 or more.
The risk calculator
The guidelines include a "risk calculator," based
on research from the famous Framingham Heart Study. It uses your age,
cholesterol levels, smoking status, and blood pressure to come up with
your risk for having a heart attack during the next decade. The
calculator does not, by itself, provide the whole picture, however, and
the results can be confusing. You should do this risk assessment test
with your doctor. The results, along with your LDL level and other
risk factors, will help your doctor determine how much you need to lower
your LDL through life-style changes and perhaps cholesterol-lowering drugs.
Still, if you want to try this formula yourself, it's easiest
to use the government's
website, which also provides lots of helpful information about coronary
artery disease. You can also get a free copy by writing to the NHLBI Information
Center, P.O. Box 30105, Bethesda MD 20824-0105, or call 301-592-8573;
ask for "High Blood Cholesterol—What You Need to Know."
Living the good life
The guidelines also stress the importance of life-style
changes, even for those taking medication.
These steps include exercising, losing weight (via calorie reduction),
stopping smoking, and especially adopting a cholesterol-lowering diet.
For people with elevated blood cholesterol and risk factors, the dietary
goals are stringent: lower saturated fat (less than 7% of total calories,
instead of 10% on the usual heart-healthy diet) and lower dietary cholesterol
(less than 200 milligrams a day, down from 300). But they do allow for
more monounsaturated fat (up to 20% of total calories, instead of 10 to
15%, especially for those with diabetes or the "metabolic syndrome"
described above). There's also new emphasis on consuming lots of cholesterol-lowering
soluble fiber, like that found in oats and beans, along with plant compounds
called stanols or sterols, found in some specialty margarines, such as
Benecol.
Most people, and many doctors, are going to focus on the
drug advice in the new guidelines, rather than the life-style advice.
That would be a mistake. Statin drugs are expensive—$1,000 to $1,800
a year—and presumably you'll have to take medication for life. While
they seem to be safe and work well (and may have other benefits, too),
statins can cause minor side effects, such as gastrointestinal upset,
sleep problems, and rashes. More rarely, statins can cause severe muscle
and liver damage, so you need periodic blood tests for liver function.
In addition, no one knows how safe they are when taken for many years
or decades.
Last words
The new recommendations make it all the more important that you talk to your doctor about heart disease. They also make it more likely that doctors will quickly put more patients on statins (or other cholesterol-lowering drugs). That will save lives, but having tens of millions of Americans on cholesterol-lowering drugs is a far-from-perfect solution. Most people don't give life-style changes a real chance, and their doctors don't help them enough in their efforts. Take medication if you need it, but make sure you really need it first. Losing weight, becoming more active, improving your diet (especially by eating more fruits, vegetables, and whole grains), and stopping smoking will help keep you healthy in many ways besides lowering your cholesterol. These steps, for instance, will also help prevent diabetes and "metabolic syndrome," two of the big risk factors for heart disease.
UC Berkeley Wellness Letter, August 2001