The Covert Rationing Blog

How Important Is Cholesterol, Really?

January 24th, 2008 by DrRich

In addition to being the Rabble-Rouser-In-Chief for this fine blog and its groundbreaking parent website, DrRich for several years has also been the cardiology expert at About.com. (About.com is a New York Times company, but since his association with About.com predates that of the NYT, DrRich sincerely hopes that his more conservative readers will not hold this against him.) In this capacity, DrRich routinely tries to clarify for his readers (who are mainly patients with heart disease and their loved ones), controversial topics in heart disease. Because cardiologists (like all theologians) never tire of arguing over how many angels can dance on the distal pole of a defibrillation lead, and because the popular media delights in reducing these arcane arguments to breathless (and commonly misleading) headlines, there is a never-ending cascade of material upon which DrRich can draw.

Most recently, the results of a clinical study called ENHANCE has had many in the popular media (in response to new concerns voiced by medical experts), questioning the deeply-entrenched cholesterol paradigm - that is, the idea that LDL cholesterol (the bad kind of cholesterol) is indeed bad, and that anything we can do to lower it is good. Questioning the cholesterol paradigm - a belief system we’ve all been taught since we were babes in arms - is deeply disturbing, confusing and troublesome to many American patients (judging, at least, from the response DrRich has received from readers of his heart disease site).

These patients have been told for years to arrange their lives around the reduction of their cholesterol levels. And while the proportion of people who actually do so does not exceed the proportion who, in earlier times and under a different paradigm, actually arranged their lives so as to further their odds of spending eternity in paradise (modern sinners often preferring instead to rely on today’s equivalent of the deathbed conversion - the stent), the sudden notion that the cholesterol god is dead leaves these patients unbalanced, uncentered and oddly empty. They are also beginning to believe that their doctors, who (some appear to be saying) have been preaching a false doctrine at them for many decades, are even more full of cr*p than previously thought.

In response to this existential crisis, and so as to fulfill his duties to About.com and its parent company, DrRich has posted an article that purports to place all this in perspective, and more importantly, to give patients some guidance as to how to proceed in regard to their cholesterol therapy NOW (i.e., during the next 10 years or so, while the experts debate the issue, and argue over whether the current guidelines - the following of which doctors will continue to be paid-to-perform - actually make sense.)

Normally, DrRich would not trouble readers of the Covert Rationing Blog with topics pertaining to his other duties. But this recent cholesterol controversy has already attracted the attention of other medical bloggers he admires, some of whom have offered (for instance, here and here) very level-headed opinions on the matter. Frankly, while DrRich is clearly very comfortable pontificating on matters related to healthcare reform (and most other topics), he gets nervous touching on theology or its close relative, cholesterology. So DrRich will be very interested to know from readers of this blog if his advice - which, again, is aimed at American patients - seems sufficiently clear, and most of all, reasonable. The posting can be found here.

Thank you for your indulgence.

Posted in Cardiology Topics

3 Responses to “How Important Is Cholesterol, Really?”

1. A Skeptic wrote on 01/24/08 at 8:04 pm :

   I would like to hear your views on the current practice of prescribing lipid lowering therapy to “goal”. Wouldn’t it make more sense just to identify the high risk patient by baseline LDL level, prescribe a high potency statin at the highest tolerated dose, and just continue it indefinitely with perhaps occasional LFT’s but no other repeated laboratory testing? Do we gain anything other than a better number by adding additional drugs (niacin, fibrates, etc.)which add additional potential toxicity? I think this is the more important question. I don’t think there’s any evidence-based answer.

2. DrRich wrote on 01/24/08 at 8:57 pm :

   Skeptic,

   Most of the studies done with statins actually did not aim for a specific cholesterol goal, but instead simply randomized patients to a fixed dose of a statin (usually a “high” dose) vs. some other treatment. The cholesterol treatment goals that are talked about in the guidelines, as nearly as I can tell, were derived from the cholesterol levels achieved in such trials. This is logical if the therapeutic benefit is actually related to the post-therapy cholesterol level. But if the therapeutic benefit is actually due to the cumulative effects of the statin, then that benefit would be achieved, as you suggest, without ever measuring a follow-up cholesterol level.

   The fact that we don’t know the answer to this question has less practical import than you might think, since, if higher doses of statins are used, in general the reduction in cholesterol levels will hit the “target” in any case. Using drugs other than statins rarely comes in to play, practically speaking, unless statins are not tolerated, or unless niacin is added to further increase HDL levels.

   More commonly docs will start with a low statin dose, then measure cholesterol levels to see if more statin is needed in order to hit the target cholesterol level. If docs started with the higher doses of statins used in the clinical trials, your strategy would probably work out just fine in the majority of patients.

   DrRich

3. Dr. Val wrote on 02/3/08 at 6:26 pm :

   I thought your summary article was great. Thanks for taking the time to put it all together.

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