Cholesterol goals for people who already have heart disease

Are you someone who has already had a heart attack or currently has angina and your doctor has told you that you need to lower your cholesterol level?  My patients worry that once they’ve been diagnosed with a heart problem, it’s too late to do anything to help.  After all, starting a program aimed at lowering cholesterol after a heart attack or the onset of angina or other circulatory problems seems a bit like closing the barn door after the horse has gone. The good news is that this isn’t so.  In fact, there is far better evidence for the benefits of cholesterol-lowering therapy in this group of people than there is for people who haven’t been diagnosed with heart disease and who don’t have any symptoms other than high cholesterol.

People who have had a heart attack; who have a condition such as angina, peripheral artery disease, abdominal aortic aneurysm, or symptomatic carotid artery disease; or who have had bypass surgery or angioplasty are five to seven times more likely than others to develop new or recurrent heart disease. Study after study has shown that people who already have heart disease benefit from lowering their cholesterol. No matter what method they choose, they will improve their chances of avoiding a second heart attack or another procedure to open plaque-narrowed arteries.

Indeed, data from the 1999 Atorvastatin versus Revascularization Treatment study suggest that statins — when used aggressively to lower total cholesterol and LDL — are as effective as angioplasty in helping people avoid subsequent heart attack, stroke, sudden heart-related death, or hospitalization for worsening angina or to open a clogged coronary artery. In this study, 341 people with stable coronary artery disease were randomly assigned to take daily atorvastatin pills or to have an angioplasty. After 18 months, those taking the statin were less likely to have had a worsening of their angina or to have needed bypass surgery than those who had undergone angioplasty.

Before that, the 1994 Scandinavian Simvastatin Survival Study was the first to document that lowering cholesterol helped heart disease patients live longer. And since then, a number of studies have demonstrated the same thing, including several that garnered big headlines. Both the PROVE-IT and IDEAL trials, for example, showed that very aggressive treatment of cholesterol levels in people who had recently had heart attacks reduced the number of additional heart attacks and other adverse events. The ASTEROID study showed that people who had experienced angina and other symptoms, indicating they were at risk of having a heart attack, could actually reverse the process of atherosclerosis with high-dose statin therapy — although it’s not clear if this would reduce their risk of heart attack or stroke.

Both the National Cholesterol Education Program (NCEP) and the American Heart Association (AHA) recommend aggressive cholesterol-lowering therapy for anyone who survives a heart attack or thrombotic stroke — or who is diagnosed with some other form of heart disease — and whose LDL level is greater than 100 mg/dL. The latest NCEP guidelines notes that an LDL goal of under 70 mg/dL for people who have heart problems is worth considering. People who are taking cholesterol-lowering drugs should also follow a healthier diet and keep exercising. Besides having other health benefits, diet and exercise enhance the effects of drug therapy.

Some physicians wait several weeks after a patient has had a heart attack or other coronary event before suggesting a cholesterol test and recommending cholesterol-lowering therapy. The delay allows total cholesterol and LDL to return to their usual levels and thus yields more accurate testing results. It also reflects the theory that any benefits from statins appear only after long-term use. But evidence suggests that statins have beneficial effects apart from lowering cholesterol — such as helping blood vessel walls function better — that may appear after only a few weeks of therapy. Such evidence has prompted clinicians to prescribe statins sooner. The results from the PROVE-IT trial made the same point, since the researchers began to see fewer heart attacks, strokes, deaths, and other events in the super-low-LDL group after just 30 days of treatment.

Yet despite strong evidence that cholesterol-lowering therapy is safe and effective in people with existing heart disease, many people who merit this therapy don’t receive it. Some doctors fail to recommend the medication, and some patients fail to take it even when their doctors prescribe it. If you have a heart attack or develop some other form of heart disease, and your physician doesn’t suggest checking your cholesterol levels and treating them if they don’t meet the NCEP guidelines, raise the issue yourself and discuss the treatment options with your doctor.

If you have heart disease, what did your doctor say about the importance of keeping heart disease risk factors in line? Did he or she recommend a cholesterol-lowering medication or lifestyle?

Julie K. Silver, M.D., is an assistant professor in the Department of Physical Medicine and Rehabilitation at Harvard Medical School. She is also the Chief Editor of Books for Harvard Health Publications.

High Cholesterol
High cholesterol is a major contributor to heart disease, but how can you tell how much cholesterol is too much? What is the difference between “good” and “bad” cholesterol, and how can you achieve a healthy level of each? What to do about High Cholesterol is a special report from Harvard Medical School that gives you a step-by-step plan to set and reach your own cholesterol-level goal. Get tips on diet and exercise, medication options, and everything else you need to start lowering your cholesterol today.

Are you Living With High Cholesterol? Connect with others with similar health concerns and issues. Click here to join the group.