How Low Can You Go?

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tors often caution their patients not to put too much stock in the results of a single medical study. After all, researchers are human, too, and can make mistakes. But when five different clinical trials published over three years concluded that lower cholesterol levels would better protect folks at greatest risk of heart attack, the evidence seemed too strong to ignore. That's why the experts at the National Cholesterol Education Program (NCEP) decided to change their guidelines — setting aggressive new targets that will take some getting used to.

The revised guidelines focus on low-density lipoprotein (LDL)--the so-called bad cholesterol. Four years ago, the NCEP recommendations were that patients at high risk of heart attack — including those who have diabetes or already have heart disease — try to get their LDL level under 100 mg/dL. But the guidelines allowed some wiggle room — up to 129 mg/dL. The latest update eliminates the wiggle room for high-risk patients.

It also creates a category of patients at "very high" risk — a group that includes heart patients who smoke, diabetics with heart problems and people who are in the hospital for their heart condition. Under the new guidelines, doctors have the option of treating these patients even more aggressively by lowering their LDL cholesterol to less than 70 mg/dL. There was grumbling among some cardiologists who thought that for very-high-risk patients the lower figure should have been made mandatory. It very nearly was, says Dr. James Cleeman, the NCEP coordinator, but the evidence supporting such a move was "just short of conclusive." He expects the results of three more clinical trials, due to be completed in the next couple of years, to settle the matter.

The new recommendations are likely to sharply increase the use of statin drugs. It's almost impossible to achieve such low LDL levels without the cholesterol-cutting medications, and last week consumer groups complained that the NCEP committee failed to disclose that at least six of its nine members had financial ties to companies that make them. But even the NCEP says the best ways to lower cholesterol are to get more exercise, eat less saturated and trans fats, and maintain a healthy weight. "Patients often think, Since I'm taking a statin, I'm protected," says Dr. Eric Topol, a cardiologist at the Cleveland Clinic. But although statins can reduce the risk of a heart attack, they won't eliminate it.