Do You Need Treatment?

All signs point to elevated levels of LDL cholesterol as a major cause of heart disease. And the research on cholesterol-lowering drugs clearly demonstrates that lowering LDL cholesterol reduces the risk for heart disease. There is growing evidence that the more you reduce your cholesterol level, the more you reduce your risk of developing cardiovascular disease.

So how do you know if you need to take steps to reduce your cholesterol? To help people and their physicians answer this question, the NCEP has set out some practical guidelines for recognizing and treating high cholesterol.

Treatment decisions should not be based solely on your cholesterol level. You and your doctor must also take into consideration your current health status and your risk for heart disease. The NCEP guidelines emphasize the importance of interpreting an individual's cholesterol profile in the context of his or her overall risk. Likewise, the intensity of treatment should be based on the individual's risk status. Those who already have heart disease or diabetes and those who are at high risk for heart disease should receive more aggressive treatment than patients at lower risk.

Step 1: What are Your Cholesterol Levels?

Review the results of your fasting lipid test and compare them with the NCEP guidelines for favorable levels (see Table 1).

Total cholesterol. This number is the sum of cholesterol carried in all cholesterol-bearing particles in the blood, including HDL, LDL, and VLDL. Although the total cholesterol level closely parallels the LDL level in most people, there are enough exceptions to that rule to make it useful to test for LDL, HDL, and triglycerides separately. The NCEP guidelines say a total cholesterol level below 200 mg/dL is desirable, 200–239 mg/dL is borderline high, and 240 mg/dL is high.

HDL cholesterol. HDL fights plaque buildup in the heart's arteries, and the more HDL you've got, the better. The NCEP guidelines consider levels of 60 mg/dL or above to be high enough to provide protection. HDL levels of less than 40 mg/dL are regarded as too low and increase your risk of heart disease.

Some clinicians use the ratio of total cholesterol to HDL cholesterol to help identify people who need cholesterol-lowering therapy. The more HDL you have relative to total cholesterol, the smaller and healthier the ratio. Reports from the Framingham Heart Study suggest that for men, a total-to-HDL cholesterol ratio of 5 means average risk, 3.4 means about half the average risk, and 9.6 means double the average risk. For women, a ratio of 4.4 works out to be average risk, 3.3 is half the average, and 7 is twice the average.

For the vast majority of people, it doesn't much matter whether you use the HDL level or the ratio of total cholesterol to HDL. Most people with a high level of total cholesterol also have an unfavorable ratio and would be targeted for intervention under either system. Still, a few people may find that the ratio provides a strikingly different assessment of their coronary risk. Someone with a healthy total cholesterol of 195 mg/dL, who would be labeled low risk under the old system, might in fact be headed for heart disease if his or her total-to-HDL cholesterol ratio was too high because of a low HDL level. Conversely, someone with a total cholesterol of 250 mg/dL — who would ordinarily be put on a treatment program — might actually need little more than the usual lifestyle changes if a high HDL level accounted for a good proportion of the total, producing a low ratio.

LDL cholesterol. Your LDLs are the most significant of the blood lipids that raise your risk for heart disease, so lowering your LDL should be the primary target of therapy. For LDL, below 100 mg/dL is optimal, 100–129 mg/dL is near optimal/above optimal, 130–159 mg/dL is borderline high, 160–189 mg/dL is high, and 190 or above is very high. The July 2004 NCEP addendum states that a target LDL as low as 70 is an option for people at the highest risk for experiencing a new coronary event, such as a heart attack, angina, or heart surgery. This change is based on evidence from several clinical trials that showed that high-risk people had fewer new coronary events if their LDLs were lowered substantially below 100 mg/dL. Depending on your other cholesterol levels and other risk factors, your therapy to lower LDL may involve lifestyle factors, such as diet and exercise, or the use of cholesterol-lowering medication.

Triglycerides. Many studies have indicated that as triglyceride level rises, so does heart disease risk, but the link seems to vary depending on what other risk factors are present. Triglyceride levels also vary considerably in response to what a person has eaten just before the blood test. And many substances or medical conditions can cause high triglyceride levels — for example, uncontrolled diabetes, corticosteroids, thiazide diuretics, or too much alcohol.

Recommendations suggest more aggressive treatment for elevated triglycerides. Studies indicate that an elevated triglyceride level is significantly linked to the degree of heart disease risk. The recommendations say to treat even borderline-high triglyceride levels. Therapy includes weight control and physical activity — and sometimes, for higher triglyceride levels, medication.

The guidelines for triglyceride levels say that below 150 mg/dL is normal, 150–199 mg/dL is borderline high, 200–499 mg/dL is high, and 500 mg/dL and above is very high.

High triglyceride levels should prompt a search for an underlying cause, such as alcohol abuse, liver disease, medications, an underactive thyroid gland, or undetected diabetes. People with combined hyperlipidemia, a condition marked by high LDL and high triglyceride levels, often suffer from a genetic disorder, although some of them have acquired the condition from being obese or using alcohol heavily.

Step 2: Do You Have Heart Disease, Diabetes, or Chronic Kidney Disease?

The next step is to assess the current state of your cardiac health. Do you have any form of coronary artery disease, peripheral artery disease, disease of the carotid arteries (the vessels that deliver blood to your brain), or an abdominal aortic aneurysm (a bulge in the artery delivering blood to the body)? If so, your risk of a heart attack increases. According to the American Heart Association, 18% of men and 35% of women will have another heart attack within six years of having their first.

Researchers now know that diabetes and chronic kidney disease carry similar risks for heart health. So if you have diabetes, chronic kidney disease, or any of the above heart conditions, you'll probably be in the most aggressive treatment group, so you can skip over the next two steps and go to step 5. If not, go to step 3.

Step 3: How Many Risk Factors Do You Have?

As discussed earlier, there are a lot of risk factors that increase your chance of having a heart attack. Count your major risk factors, as follows:

• high blood pressure (greater than 140/90 mm Hg, or any number if you're on blood pressure drugs)

• family history of early heart disease (occurring before age 55 in male first-degree relatives and 65 in female first-degree relatives)

• cigarette smoking

• age 45 or over in men, and 55 or over in women.

Although other minor factors like an unhealthy diet or lack of exercise are not included in this part of the analysis, you and your doctor should take them into consideration.

If you have no more than one of the major risk factors, skip to step 5. If you have more than one major risk factor, go on to step 4.

Step 4: What's Your Heart Attack Risk?

Use the Heart Attack Calculator (see Table 2 if you are a man or Table 3 if you are a woman) to determine your risk of having a heart attack in the next 10 years. Note that a 3% risk means that 3 out of 100 people with your risk profile will have a coronary event in the next 10 years, a 10% risk means that 10 out of 100 people with your risk profile will have a coronary event in the next 10 years, and so on.

Step 5: Finding Your Treatment Category

Armed with your answers to steps 1–4, determine your treatment category (see Table 4). From this, you can determine the LDL levels you should strive for and what kind of treatments your doctor may recommend.

A Lower Cholesterol Goal?

In July 2004, the NCEP updated guidelines, noting that people in the category of very high risk for heart disease may want to consider making their LDL cholesterol goal less than 70 mg/dL — another 30 points below the level recommended as optimal in 2001 (see Table 4). In addition, the recommendations advise that people in the moderately high-risk group may want to aim for less than 100 mg/dL, which is also 30 points below the 2001 recommendation.

The NCEP doesn't suggest making under 70 mg/dL a goal for everyone — only people at very high risk. Why? The panel decided that although the studies on which the recommendations are based are strong, they are not conclusive enough to warrant completely new guidelines. Ongoing studies may provide those data. Also, the NCEP notes that not everyone will be able to get their LDL levels below 70 mg/dL. Even with intensive therapy, people can rarely cut their LDLs by more than half. So someone with LDL levels of 150, for example, might never get below 70 mg/dL.

If you fall in the very high-risk category and have an LDL cholesterol level at or near 100, either with or without cholesterol-lowering medication, you have a few options, depending on individual characteristics. You and your doctor should decide whether you should

• start or intensify lifestyle or drug therapies to specifically lower LDL

• delay treatment in favor of first trying to change other risk factors, or in favor of trying medication to increase HDL cholesterol or decrease triglycerides

• lose weight and increase activity if you have metabolic syndrome (see "What is metabolic syndrome?").

If you're in the moderately high-risk group, how do you know if your LDL goal should be less than 130 or 100? Your doctor might ask you to adopt the lower goal if you are older or have any of the following:

• more than two risk factors or severe risk factors (like continued smoking or a strong family history of early heart disease)

• triglycerides above 200 mg/dL along with total cholesterol minus HDL cholesterol that is above 160 mg/dL

• HDL cholesterol below 40 mg/dL

• metabolic syndrome.

Many doctors are already recommending LDL targets even lower than what the NCEP currently recommends. This is a controversial area because even the advocates for lower LDL levels admit there is currently no scientific proof that doing so will improve health in most people. Just because lower LDL levels were shown to help people with recent heart attacks and unstable angina does not mean that such levels would help others, including people with heart disease but who haven't had a recent heart attack, or people with risk factors for heart disease.

What does metabolic syndrome do to the body? Basically, in people with this disorder, blood sugar levels stay high after a meal or snack instead of dropping to a base level like they do in most people. The pancreas, sensing still-elevated glucose levels, continues to pump out insulin (the hormone that signals cells to take up glucose from the bloodstream). Constant high levels of insulin and blood sugar have been linked with many harmful changes, including damage to the lining of coronary arteries and other arteries, increased triglyceride levels in the blood, changes in how the kidneys handle salt, and blood that clots more easily. Long-term overstimulation of the pancreas may exhaust it, so that it stops supplying enough insulin.

This cascade of changes isn't healthy. Damage to artery walls, high triglycerides, and increased chance of blood clots can lead to heart attacks and some strokes. Changes in the kidneys' ability to remove salt contribute to high blood pressure, another path to heart disease and stroke. And dwindling insulin production by the pancreas signals the start of type 2 diabetes, which greatly increases the risk of heart attack, stroke, and damage to the nerves, eyes, and kidneys. The treatments outlined in this report can reduce your chances of having the symptoms that characterize metabolic syndrome.