Cholesterol levels lowered for heart patients

Monday, July 12, 2004 Posted: 4:20 PM EDT (2020 GMT)

http://www.cnn.com/2004/HEALTH/diet...l.ap/index.html

DALLAS (AP) -- People who have recently had a heart attack should lower their "bad cholesterol" to rock-bottom levels, according to new guidelines issued Monday.

"The concept here is that lower is better with respect to cholesterol," said Dr. Steven Nissen, cardiologist at the Cleveland Clinic, who is among those who have studied the issue. "It'll be hard to get there, but we do have aggressive drugs."

Heart patients in need of drastic measures can use statin drugs _ including Lipitor -- in higher doses or combine statins, which block formation of cholesterol, with drugs that block cholesterol's uptake by the body.

The new guideline for very high-risk heart patients is lowering their so-called bad cholesterol, LDL, to 70. The previous guideline was 100.

The new guidelines, in Monday's issue of the American Heart Association journal Circulation, are not a complete surprise. Recent studies have shown that lives can be saved by a drastic lowering of LDL in people who have had recent heart attacks.

Created by the National Cholesterol Education Program, the guidelines are endorsed by the American Heart Association, the American College of Cardiology and the National Heart, Lung and Blood Institute. A panel of the education program examined five major studies involving cholesterol-lowering medicines.

"By doing this we expect further reduction of death from heart disease, as well as heart attacks, and the need for expensive re-vascularization procedures like bypass surgery and coronary angioplasty," said Dr. Sidney Smith, a co-author, former president of the American Heart Association and professor of medicine at the University of North Carolina.

"I think that the majority of patients -- based on the studies _ should be able to achieve these goals," he said.

Every year, 1.2 million people in America have a new or repeat heart attack. Dr. Scott Grundy, lead author of the guidelines, said that as of 2001 there were about 36 million people who could benefit from drugs to lower their cholesterol. He said that it's hard to put a number on it, but the new guidelines could increase that number by "a few million."

The LDL guideline -- or option, according to Smith -- of 70 is for people who have just had a heart attack or those who already have cardiovascular disease plus diabetes, are persistent smokers and have high blood pressure, or other multiple risk factors.

Grundy, director of the Center for Human Nutrition at the University of Texas Southwestern Medical Center at Dallas, said that the updated recommendations call for drug therapy in almost all high-risk patients with levels of LDL higher than 100.

For moderately high-risk people -- those who have multiple risk factors and are estimated to have a 10 percent to 20 percent chance of heart attack or cardiac death within 10 years -- the new guidelines reinforce the need for treatment if LDL levels are 130 or higher and add an optional consideration of drug therapy if levels are between 100-129.

The guidelines have not changed for those in the lower to moderate risk categories. Grundy said those in the low risk category should be keeping their LDL level at 160 or lower and moderate risk patients should be keeping it at 130 or lower.

Dr. James Cleeman, coordinator of the National Cholesterol Education Program at the National Heart, Lung and Blood Institute, said patients should also be doing things like eating a diet low in saturated fat and cholesterol, exercising and keeping their weight under control.

Ah, but do all those drugs also lower HDL? It's also been shown that too low an HDL level is also a risk factor for early death, including suicide.

And I'd like to see what studies prove that lowering LDL is that beneficial. Especially when there are some types of LDL that are good for you.

I don't suppose they were considering that Dr. Scott Grundy is strongly associated with both the AHA and the NIH and is a well known proponent of statin therapy even at high dosages.
IIRC, Dr. Scott Grundy was also instrumental in introducting the current AHA diet to the AHA and pushing for its widespread prescription and use.

Here are some additional articles that might be of interest:

http://www.ravnskov.nu/cholskept.li...bes.respons.htm
http://bmj.bmjjournals.com/cgi/eletters/323/7322/1145

On the way home from work this afternoon I was listening to a news story on the radio about the growing numbers of Americans over 65 who are filing for bankruptcy. The major cause - increasing health care costs. And the major portion of health care costs – why prescription drugs, of course. Guess there will be even more bankruptcies as seniors try to get those LDL levels down.

Polypharmacy, defined as being on more than 5 drugs, prescription or not, is a growing problem in this country....for young and old. People go to their doc for a problem and they're given a med. They have a reaction to the med and are given another med. At the same time, they're usually self-medicating with at least one OTC med, at least occasionally. Today, it's not uncommon for docs to go ahead and give a second prescription to fight common side-effects.

And if nothing works to control the side effects? Well in the case of statins, you just gotta suck up and deal with it.

We have to get away from this "a pill can cure it" mentality!

I'm still predicting a proposal to add statins to our drinking water within 10yrs.

I keep seeing references citing that it's the type of LDL (small dense or large fuffy) that determines ones risk. If you have large fluffy LDL and you take drugs to low it, then won't you actually be increasing your risk?

You certainly won't be helping your cause any if you lower your levels of the beneficial type of LDL and at the same time do nothing for your levels of triglycerides which low fat dieting typically raises (along with lowering your HDL) and statins do nothing to lower. Additionally, the types of fats usually prescribed with a typical low fat diet may actually be working against the mechanism of action of statin drugs (decreasing inflammation) by increasing or promoting inflammation.
On top of that, LDL is only a small piece of the puzzle here along with triglycerides, HDL levels, homocysteine levels and c-reactive protein levels. It bothers me tremendously that doctors are willing to promote and prescribe statins despite the risks when they only address a portion of the issue and the benefits that they may provide may not outweigh the risks.
As CindySue pointed out, we as a society have bought hook, line and sinker the idea that pills can fix everything when all they really do is address the symptoms and not the cause itself.

Can you imagine the massive amount of money this represents ??? The entire health industry is driven by big pharma. Doctors are trained to be pill pushers. They are constantly solicited by the drug industry to prescribe more drugs. Indeed, what constitute ongoing education for doctors is sponsored by the industry as well. And the majority of research is sponsored by the drug industry to develop more drugs to sell. It seems to me that all the research done about how the body works is an excuse to develop a drug to block this or that.

Finally, patients have come to expect drugs to be the answer to everything. So even when you have doctors who don't believe in over prescribing, the patients demands it.

How many stories have you heard about an ederly person who starts to rapidly decline after they are prescribed one pill after another. You have to wonder if they might have be better off taking nothing at all.

So all it all it's a pretty sad state of affairs. I really dont see things changing anytime soon.

the authority was completely silent on triglycerides. -NO MENTION-
triglycerides/HDL is a better marker for CHD.

This is bullcookies. The doctors are bought and paid for by big pharma, and my Dr. is going to get an earful for being part of his "profession."

Don't be too mean to your doctor... you may need him/her one day.

Well that depends a lot on which doctor. who is paying them and how much misguided influence they have on health policy.

Dr Scott Grundy wrote this;

"Dietary Fat: At the Heart of the Matter

The role of dietary fat in the causation of coronary heart disease (CHD) has long been a topic of interest and dispute. In his News Focus article, Gary Taubes discusses what he calls "The soft science of dietary fat" (30 Mar., p. 2536). He reviews the history of the diet-heart issue and concludes that public health recommendations regarding dietary fat have not been based on solid science. He is primarily critical of the "low-fat" recommendation that has long been made by authoritative bodies to the American public. Taubes covers many aspects of the diet-heart issue, but he focuses on the question of whether there has been an overemphasis on fat without sufficient evidence that dietary fat is a major cause of CHD. He points out that recent trends in heart disease mortality both in the United States and worldwide are not well correlated with changes in dietary fat intake. Certainly he makes several astute observations, but in some areas, particularly in cardiovascular epidemiology, he does not appropriately recognize several other factors that confound the role of certain dietary fats in causation of CHD.

In my view, Taubes does not rightly identify saturated fatty acids as the predominant dietary factor contributing to the development of CHD. The significance of saturated fatty acids has been demonstrated by an enormous number of high-quality studies carried out with dietary fat in the fields of animal research, epidemiology, metabolism, and clinical trials (1). Although all questions have not been answered, a clear picture of the metabolic and health effects of saturated fatty acids has emerged. One fact is incontrovertible. As shown in multiple metabolic studies in humans, saturated fatty acids as a class, compared with unsaturated fatty acids and carbohydrate, raise serum low-density lipoprotein (LDL). Evidence is abundant that elevated LDL is a major cause of CHD and that lowering serum LDL levels reduces CHD risk (2). Even moderate reductions in LDL levels, such as those obtained by reducing dietary saturated fatty acids, are projected to substantially reduce risk of CHD in populations (3). Early prospective epidemiological studies gave results that are consistent with these projections (4). For example, in Northern and Eastern Europe, where intake of animal fats (mostly saturated fatty acids) previously was very high, serum LDL levels and CHD rates also were high. Conversely, in Southern Europe, where plant oils (mostly unsaturated fatty acids) are the predominant fat source, serum LDL levels and CHD rates were much lower. These relations were established more than 30 years ago, before increasing social and cultural homogenization in Europe partially obscured the relation of dietary fat to CHD (4). These population results, which in themselves were suggestive although perhaps not definitive, have been confirmed by results of controlled clinical trials. Several trials reveal that substitution of unsaturated fatty acids for saturated fatty acids lowers the incidence of CHD (1).

Although Taubes acknowledges the difference between saturated and unsaturated fatty acids, he does not draw a clear enough distinction in his discussion of dietary fats in general. Consequently, the article obscures the potential for public health benefits of substituting unsaturated for saturated fatty acids in the American diet. Such confusion does a disservice to the public health effort to further reduce the incidence of CHD through a reduction in intake of saturated fatty acids. On the other hand, Taubes does rightly note that other nutritional factors, for example energy imbalance leading to obesity, excessive carbohydrates, and insufficient intake of fruits and vegetables also influence population risk for CHD (1, 2).

Scott M. Grundy
Center for Human Nutrition and the Departments of Clinical Nutrition and Internal Medicine,
University of Texas Southwestern Medical Center,
Dallas, TX 75390-9052, USA.
E-mail: scott.grundy ~utsouthwestern.edu

References and Notes
1. Report of the Dietary Guidelines Committee on the Dietary Guidelines for Americans, 2000 (U.S. Department of Agriculture, Agricultural Research Service, Washington, DC, 2000).
2. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, J. Am. Med. Assoc. 285, 2486 (2001).
3. M. R. Law, N. J. Wald, T. Wu, A. Hackshaw, A. Bailey, Br. Med. J. 308, 363 (1994).
4. A. Keys et al., Am. J. Epidemiol. 124, 903 (1986). "

But the real story (and the dishonesty of Grundy et al) is told here;


"Studies of Dietary Fat and Heart Disease

22 FEBRUARY 2002 VOL 295 SCIENCE

In his letter about the article "The soft science of dietary fat" (News Focus, G. Taubes, 30 Mar. 2001, p. 2536), Scott M. Grundy says that saturated fatty acids (SFA) are the main dietary cause of coronary heart disease (CHD) ("Dietary fat: at the heart of the matter," 3 Aug., p. 801), and he cites two reviews in support (1, 2).

In one of the reviews, there are no references (1); in the other, of which Grundy is a co-author, most of the references do not appear to be supportive of his statement (2). For instance, the authors say that "populations consuming diets high in saturated fats have relatively high levels of serum cholesterol and carry a high prevalence of coronary heart disease" (2, p. 34), referring to 12 studies (3-14). In the eight cohort studies (3-10), only one had examined the association between SFA and serum cholesterol (10), five found no increased SFA consumption among CHD patients (3, 4, 6, 9, 10), and one found a smaller consumption (7).

In addition, three of the 12 studies were reports from a project comparing the incidence of CHD in native Japanese living in Japan with Japanese-Americans living in the United States (12-14). Although it is correct that the Japanese-Americans, on average, had higher cholesterol, ate more saturated fat, and had a higher incidence of CHD, the determining factor for heart disease was not their cholesterol levels or their diets, but how acculturated they were to Western culture (13).

Grundy also writes in his letter that lowering serum LDL cholesterol by dietary means reduces CHD risk. But the study he cites did not specifically address this question (15), and more to the point, meta-analyses of all controlled and randomized trials that have used modification of dietary fat as the only type of intervention have shown that neither the incidence of nonfatal CHD, nor coronary or total mortality, was lowered significantly (16, 17).

Grundy's way of presenting scientific data is not unique. An analysis of three influential reviews in this field showed that insignificant findings in favor of the diet-heart connection were systematically inflated, and unsupportive studies were either not included or they were quoted as if they were supportive (18).

UFFE RAVNSKOV,* Magle Stora Kyrkogata 9, S- 22350 Lund, Sweden.
CHRISTIAN ALLEN.
DALE ATRENS, Department of Psychology, University of Sydney, Australia.
MARY G. ENIG, Nutritional Sciences Division, Enig Associates, Inc.,
BARRY GROVES,
JOEL M. KAUFFMAN, Department of Chemistry and Biochemistry, University of the Sciences, Philadelphia, PA, USA.
ROLF KRONELD, University of Åbo (Turku), Finland.
PAUL J. ROSCH, New York Medical College, Yonkers, NY, USA.
RAY ROSENMAN,
LARS WERKÖ,
JØRGEN VESTI NIELSEN, Department of Internal Medicine, Karlshamn Hospital, Sweden.
JAN WILSKE, Department of Internal Medicine, Värnamo Hospital, Sweden.
NICOLAI WORM,
*To whom correspondence should be addressed. E-mail: uffe.ravnskov~swipnet.se
†Former director of cardiovascular research, SRI International.
‡Former head of the Department of Medicine, Sahlgren's Hospital, Gothenburg; former scientific director at Astra Company; and former head of Swedish Council on Technology Assessment in Health Care, Stockholm.

References and Notes
1. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, J. Am. Med. Assoc. 285, 2486 (2001).
2. Report of the Dietary Guidelines Committee on the Dietary Guidelines for Americans, 2000 (U.S. Department of Agriculture, Agricultural Research Service, Washington, DC, 2000).
3. R. B. Shekelle et al., N. Engl. J. Med. 304, 65 (1981).
4. D. Kromhout, C. D. L. Coulander, Am. J. Epidemiol. 119, 733 (1984).
5. D. L. McGee et al., Am. J. Epidemiol. 119, 667 (1984).
6. L. H. Kushi et al., N. Engl. J. Med. 312, 811 (1985).
7. P. Pietinen et al., Circulation 94, 2720 (1996).
8. K. L. Esrey, L. Joseph, S. A. Grover, J. Clin. Epidemiol. 49, 211 (1996).
9. F. B. Hu et al., N. Engl. J. Med. 337, 1491 (1997).
10. R. B. Singh et al., J. Am. Coll. Nutr. 17, 342 (1998).
11. A. W. Caggiula, V. A. Mustad, Am. J. Clin. Nutr. 65 (suppl.), 1597S (1997).
12. A. Kagan et al., J. Chronic Dis. 27, 345 (1974).
13. M. G. Marmot et al., Am. J. Epidemiol. 102, 514 (1975).
14. R. M.Worth et al., Am. J. Epidemiol. 102, 481 (1975).
15. M. R. Law et al., Br. Med. J. 308, 363 (1994).
16. U. Ravnskov, J. Clin. Epidemiol. 51, 443 (1998).
17. L. Hooper et al., Br. Med. J. 322, 757 (2001).
18. U. Ravnskov, J. Clin. Epidemiol. 48, 713 (1995)."

Cheers,

Malcolm

Sorry to say, statins will remain BIG business for a long time to come. The money surrounding them creates this reality distortion field.

1. Statins give doctors an easy fix. All the tired old advice about 'eat right and exercise' or 'eat low fat' rarely lowered cholesterol by much. If at all. Now they have a magic bullet. They will not give it up, unless they see themselves getting sued for using statins. Now, they fear getting sued for NOT using them.

2. There is HUGE money to be made through the fear of cholesterol. No one will let that go away, least of all the pharma. Notice the Lipitor ads. "Hey, look at this beautiful person. All is wonderful, right? Nope, her cholesterol is 274. She is DOOMED." Of course, notice that the ads say "NOT SHOWN TO PREVENT HEART DISEASE."

3. The money surrounding cholesterol will distort and pervert basic science for years to come. Right now, you can get ALL the funding you want to run studies showing how statins cure something or other. Or showing microeffects on LDL or other molecules components. Try to get funding that looks at some other possible cause, other possible avenues, and you'll be turned away. Scientists know this. Even the researchers who are exploring the CRP approach have to involve statins, or they don't get funded. Malcolm Kendrick wrote an interesting piece about this recently. If there's no pill hingeing on the outcome, no one will pursue it.

Same thing is happening in Alzheimer's research. Any research that doesn't involve amyloid (their version of the 'cholesterol' hypothesis) just won't get funded. Period.

There's big money and big careers in cholesterol and its fear. There's no money or prestige in any other approach. Guess which will win?

K Walt,

I couldn't agree more.

Your post amplified my comment that this latest announcement is bullcookies. Indeed, I was just thinking this morning that "They will not give it [statins], unless they see themselves getting sued for using statins."

I went to www.lipitor.com to see whether you were correct about the warning that "It has not been shown to prevent heart disease or heart attacks." What you say is precisely true. Moreover, you can copy text from much of that website, but try copying the test of the warning to the clipboard on your computer.

PacNW

That's because they've made it a picture, an image rather than text. You can save the image by right-clicking (control-click on a Mac) and selecting "Save picture as..." or "Save Image As..." and tell it where to save it.

Hmm.

Anyway, to strengthen the anacdotal evidence that dietary fat has little to do with cholesterol, I've upped my fats to around 60% of my diet, much of it saturated fat and I just got my lipid numbers back.

What's strange is that my overall number is right about the same as it was two years ago. (pre-low carb) My triglycerides have come down just a bit (not as much as I thought they would), my HDL has gone up and my LDL stayed about the same. Overall, not much movement.

Total 235
HDL 43
LDL 164
Tri 140

Not great numbers, like some here, but not horrible either. If you listen to the AHA then with all of the saturated fat I eat I should be in the hospital with sky-high numbers. Instead, I've lost over 40 pounds, I exercise five-days a week and eat tons of vegetables. I have a feeling these are just the basic numbers my body will always have. I'll have them checked again later this year, November maybe. We'll see what happens then. Anyone else not see much change in their numbers?

Plane Crazy