Guidelines may boost cholesterol intervention for more patients

Effective treatments are available, but physician and patient adherence remains a challenge.

By Victoria Stagg Elliott, amednews staff. March 12, 2001.

New government guidelines outlining the means for detecting, evaluating and treating high blood cholesterol will expand recommendations for intervention to an increasing number of patients, according to cholesterol experts who have seen drafts of the report. Included in the new guidelines are patients with normal cholesterol levels who exhibit other factors that put them at high risk for heart disease, such as diabetes.

"[The recommendations] will include more people for more aggressive therapy, people with multiple risk factors whose risk adds up to something," said Paul Ziajka, MD, PhD, director of the Florida Lipid Institute in Orlando.

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These updated recommendations by the Adult Treatment Panel of the National Cholesterol Education Program at the National Heart, Lung and Blood Institute are expected in May. They were last revised in 1993. Since then, mortality from heart disease has declined but still remains the No. 1 killer in the United States.

"The 1993 guidelines were remarkably forward looking," said James Cleeman, MD, coordinator of the cholesterol education program at the NHLBI. "But there have been quite a lot of trials since 1993 and we have a lot of new information."

The new guidelines are expected to address new information on differing cardiovascular risk factors between men and women and among different ethnic groups, screening recommendations for young adults and new targets for LDL cholesterol levels in patients who already have heart disease. They also likely will include treatments that address high triglycerides, the significance of nutrition in treatment and prevention and whether HDL -- so-called "good cholesterol" -- should be a target of therapy.

"This will not completely change what doctors do," said Thomas H. Lee, MD, medical director of Partners Community HealthCare Inc. in Boston. "But it will clarify things, and that will really help," he said. Dr. Lee will be directing a course in June about how to put the new guidelines into practice.

Many experts said existing guidelines were useful, but several studies have found significant rates of undertreatment. The updated ones are expected to attempt to address this issue. "Some patients aren't treated at all," said Thomas P. Bersot, MD, PhD, director of the American Heart Assn. Lipid Disorders Training Center at the University of California, San Francisco. "And most patients who are actually given a prescription for any cholesterol-lowering drug remain on their initial dose forever and are not titrated to a level that is necessary for them to meet their goals."

Some experts expressed concern that, although an increase in the number of people receiving treatment for high cholesterol and other cardiovascular risk factors was a good idea, it might cause a significant economic burden that would bar access for some. Many of the cholesterol-lowering drugs are expensive. And, although initial treatment recommendations involve lifestyle changes, patient adherence to diet and exercise advice is low. Many still will ultimately end up on medication.

"It'll pose some economic challenges," Dr. Lee said. "Someone is going to have to pay for these drugs. The drug companies will be excited if these guidelines are applied correctly."

Most expect that the new guidelines will continue to recommend the standard cholesterol tests, particularly for screening for primary prevention, but lipid specialists already are using broader panel tests to get a better picture of a patient's true cholesterol-related heart disease risk. While standard tests measure HDL, LDL and triglycerides, the broader panels also give information about the exact composition of the cholesterol and a possibly more accurate picture of risk.

"If you do a regular lipid panel at a regular hospital lab, you can identify about 40% of the risk of premature disease," Dr. Ziajka said. "When you do the expanded labs, you can identify about 90% of the risk."

But some said the added data had limited utility in relation to expense for the average person. "Our problem isn't that we don't have enough information," Dr. Lee said. "Our problem is that we don't act effectively on the information we have."