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New Guidelines Say Cholesterol Levels Should Be Even Lower
Geriatric Times July/August 2001 Vol. II Issue 4
The new federal guidelines on high cholesterol prevention, monitoring and treatment are as complicated as they are radical in their departure from past guidelines. Issued by the National Cholesterol Education Program (NCEP), which is coordinated by the National Heart, Lung and Blood Institute (NHLBI), the guidelines--referred to as ATP III for short--differ significantly from the last guidelines issued in 1993. But their bottom line is that physicians need to be much more aggressive in diagnosing and treating patients because there are more people at risk for coronary heart disease (CHD) than previously thought.
The need for more serious surveillance still applies to seniors, James Cleeman, M.D., coordinator of the NCEP, told Geriatric Times. "There has been a tendency in some quarters that when a patient gets to age 70, a physician tells [them] they don't have to worry about cholesterol levels any more. Older people are in the game, not out of the game." Cleeman added that one out of three males and one out of four females over the age of 70 have a chance of having a heart attack.
The new guidelines are expected to substantially expand the number of Americans being treated for high cholesterol, including raising the number of people receiving dietary treatment from about 52 million to about 65 million and almost tripling the number of those being prescribed a cholesterol-lowering drug from about 13 million to about 36 million.
This is because the new guidelines recommend a low-density lipoprotein (LDL)--or "bad" cholesterol--level of 100 mg/dL for anyone considered at high-risk. Those with two or more risk factors or with a 20% chance of developing the disease within 10 years are considered at high risk. The 1993 guidelines set this level at 130 mg/dL. So in the past, a patient with LDL levels of 160 mg/dL would be told to reduce their levels to 130 mg/dL by making significant lifestyle changes. While ATP III intensifies the previous recommendations for diet, physical activity and weight control, now patients will almost certainly be prescribed cholesterol-lowering drugs as well.
In addition to lowering the threshold for healthy cholesterol levels, the NCEP added diabetes as a risk factor. This means someone with diabetes, even if they are otherwise healthy, is considered at high risk for CHD and should reduce their LDL level to below 100 mg/dL.
These recommendations would lead to 18% of American adults being prescribed "statin" drugs such as atorvastatin (Lipitor), simvastatin (Zocor) and pravastatin (Pravachol). Estimates are that the sales of this drug category could triple to $30 billion a year.
"Americans at high risk for a heart attack are too often not identified and, so, don't receive sufficiently aggressive treatment," NHLBI Director Claude Lenfant, M.D., told the press. "Yet, studies show conclusively that lowering the level of low-density lipoprotein... can reduce the short-term risk for heart disease by as much as 40%. Treatment may lower risk over the long-term--beyond 10 years--even more. That's why, while the intensity of treatment in ATP III is stepped up, its primary aim remains squarely on lowering LDL."
While geriatricians should treat seniors as aggressively as any other group of patients, there is a need for acute clinical judgement. Given nutritional and polypharmacy concerns, Cleeman explained, clinicians "have to use their judgement when they implement these guidelines"--SB
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