The cholesterol war rages

Not as graphically violent as the Iraq war, but probably more disastrous – killing thousands of victims daily who succumb to heart attacks and strokes – is the raging war against cholesterol and its atherosclerotic complications, caused by narrowing of the arteries supplying the vital organs such as the heart, brain and kidneys.

Many heart specialists also lament that one reason why we have not decisively won this war against cholesterol is that many physicians worldwide do not seem aggressive enough in treating cholesterol problems.

The significant benefits of the anti-cholesterol class of drugs called statins in the prevention of coronary heart disease (CHD), heart attacks and strokes are well-established.

Yet, medical experts lament that only a small number of eligible patients are currently being treated to the low-density lipoprotein cholesterol (LDL-C) goal recommended by the National Cholesterol Education Program (NCEP) in the United States. LDL-C is the bad type of cholesterol, while HDL-C is the good type of cholesterol.

The American Heart Association, the American College of Cardiology and the NCEP have all developed guidelines for improving care of patients with elevated cholesterol. However, physician adherence to these guidelines remains suboptimal.

A large "treatment gap" continues to exist between therapies recommended by national guidelines for patients with CHD and the care that they actually receive. And just like in any war, this "gap" allows the enemy to advance, and inflict serious damage.

This treatment gap has been extensively documented in both Europe and the United States. In addition, community-based retrospective studies of patients with CHD report that 43 to 67 percent have cholesterol tests, only 27 to 39 percent of patients are given anti-cholesterol therapy, and only nine to 11 percent of the total CHD population is treated to an ideal LDL-C level of less than 100 mg/dL. Only 23-31 percent of the total population is treated to an LDL-C level of 130 mg/dL.

Although patients are treated, they may not be treated to recommended goals. Failure to achieve treatment goal may be caused by inappropriate lipid medication use, low initial dosage, low-potency lipid medication use, patient non-compliance, or inadequate dose titration. The lower goal for patients with CHD or multiple CHD risk factors (RFs) also illustrate the difficulty of achieving LDL-C goal.

Several clinical trials have documented the efficacy of simvastatin in improving the lipid profile using forced-dose titration (this occurs when a patient is started on an initial dose of medicine and subsequently receives increasing doses of the medication as per study protocol), but studies of treatment with simvastatin in usual care settings are needed to guide selection of an appropriate starting dose and subsequent titration. A higher starting dose may be helpful for patients who require large LDL-C decreases to achieve the LDL-C goal.

In developing and underdeveloped countries, cost of medicine is always a problem leading to poor compliance. Statin therapy, which is one of the relatively more expensive medicines in cardiovascular medicine, may not be taken at the right dose and long enough – usually at least three years as shown by clinical studies – to give significant benefits to the patient. The introduction of an affordable simvastatin (Vidastat) by Therapharma may help alleviate this problem in Filipino patients who may need statin therapy.

New findings from the 20,000-patient Heart Protection Study (HPS) conducted in the United Kingdom show that simvastatin also cuts the risks of heart attacks and strokes in the high-risk population which includes patients with diabetes, narrowing of arteries in their legs, and a history of heart attack or stroke.

Even those high-risk patients considered to have normal or low cholesterol levels benefited from the use of simvastatin. This supports the use of statin for anybody at increased risk of either heart attacks or strokes. Although the exact mechanisms are not that well-understood, there is strong reason to believe that statins may confer clinical benefits in patients which may not be solely attributable to cholesterol-lowering. Lower LDL-C levels though are associated with more benefits. This should motivate the physicians to be more aggressive in bringing down the LDL-C of their patients to the target or desirable level.

Statins have been called as the new "super aspirins" and its sustained use in high-risk patients may not only prevent heart attacks and strokes, but may also make unnecessary immediate aggressive surgical interventions. Hence, some have referred to statin therapy as "medical bypass."

Both the physician and the patient can help fill in the treatment gap and improve the patient’s prognosis and outlook for a healthier and longer life despite his risk factors. Once this "gap" is plugged, escape of the "enemy" is not likely and the control of atherosclerotic complications may already be in sight in this tough war against cholesterol.