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By Grant E. Deger MD FACP

  I'm not afraid of death, I just don't want to be there when it happens.(attributed to Woody Allen)

Historically human populations were small until efficient agricultural techniques were developed, and until subsets of the population developed immunity to infectious scourges such as tuberculosis, plague, and smallpox. Rapid increases in human numbers and life span awaited good sewers, sanitation, vaccines, and antibiotics. In the new millennium the challenge will be to reduce premature loss of human life from cardiovascular disorders.

In practical terms there is approximately a 50-50 chance that any given one of us will die from heart attack or stroke. Cardiovascular disease kills more people than the next 7 causes of death combined An astounding 45% of women will succumb to heart attack. In comparison a much smaller 4% will die of breast cancer, but more women worry about their mammograms than cholesterol checks. If all cancer could be cured today the average human life span would increase two years. If all premature coronary artery disease could be prevented the average human life span would increase 11 years.

The NCEP (National Cholesterol Education Program) advises physicians and the public about research based data on the management of lipid disorders. Founded in 1985 this NIH funded consensus group recommends that all adults aged 20 years or older have total and HDL (High Density Lipoprotein) cholesterol measured every five years. The NCEP suggests that the LDL (Low Density Lipoprotein fraction of the total cholesterol) serve as the main index of the need for cholesterol lowering therapy, and that treatment with diet and//or drugs be initiated at levels substantially lower dm had previously been the case. Men and women should receive similar therapy. Patients who already have CAD (coronary artery disease) should be treated aggressively.

In major recent research trials the "statin' group of cholesterol lowering medications in usual doses typically lowers total cholesterol 25%, LDL cholesterol 35%, triglycerides 15%, and generally raises the "good" cholesterol(HDL)by 5-10%. In so doing the""statins" provide a consistent 30% decline in CAD morbidity and mortality without an increase in non-cardiovascular death.

Exercise and a low fat diet are essential therapy in cardiovascular health. But caution is urged in expecting too much from diets, herbs, antioxidant vitamins, or exercise alone. Most dietary low fat trials result in a 4 to 6% reduction in total cholesterol. Such a small reduction is helpful but inadequate by itself to help patients reach their goal cholesterol levels, which are generally 25 to 35% lower than baseline. Vitamins A, C, E and the dietary supplement garlic, have been extensively reviewed. There is as yet no scientific clarity to recommend their use. Exercise alone is not enough for some people with cholesterol disorders. Jim Fixx was an excellent and habitual runner who tried to protect himself from his own high cholesterol and his father's early death from CAD (heart attack). Sadly Mr. Fixx died in his late 40s of CAD.

Medication is urgently needed for those with existing cardiovascular disease, or those with multiple risk factors (male sex, smoking, hypertension, low HDL cholesterol, diabetes mellitus, sedentary life style, and obesity). Other risk factors may play a role in the number of heart attacks. Perturbations of Lp(a), fibrinogen, C-reactive protein, homocysteine, and plasminogen activator inhibitor I may explain premature heart attacks in some cardiovascular patients.

Managed care, for better or worse, has focused the attention of our nation to the bottom line. Every therapy must prove its worth or face rationing or denial. Renal dialysis is considered by many health care planners the top end of chronic health expense the system will accept. Dialysis costs $40,000 per patient per year of life saved (YOLS). There are exceptions. Cervical cancer screening (PAP smears) at $80,000 per YOLS, and hormone replacement therapy at $43,000 per YOLS, are considered reasonable expenses. Statin therapy for cholesterol problems in patients with existing CAD (secondary prevention) costs $13,000 to $27,000. The cost of medical therapy for lipid disorders in primary prevention exceeds $40,000 YOLS,except in the case of males with hypertension, obesity and a history of smoking (multiple risk factors).

A recent large trial of mostly Air Force personnel in Texas (AFCAPS/TexCAPS) emphasized anew that treatment of mild to moderate cholesterol elevations in men and women without preexisting CAD did save lives. Health financial planners might well heed the findings of the AFCAPS/TexCAPS trial. Based on that trial the number of Americans who need lipid treatment increases from the formerly accepted 12.5 million to 20 million.

While the good news is that cholesterol lowering is well substantiated to save lives, especially for those with preexisting coronary artery disease, the bad news is that the system is far from meeting its potential. Only 25% of those with CAD or at high risk for CAD are currently on treatment. It is discouraging that people are leaving our hospitals after heart attack and / or by-pass surgery and are ultimately not on lipid lowering drugs. Furthermore a shamefully low 9% of women and 20% of men are treated to the NCEP goal of a LDL fraction less dm 100 mg%.

The NCEP is focused on physician and public education to correct this problem. In its short existence, the NCEP has assisted a national decline in the daily ingestion of saturated and total fat and dietary cholesterol intake. It has witnessed a 5% drop in the mean U.S. serum cholesterol level from 213 mg% to 203 mg%. When completed in the year 2002, a huge NIH study called ALLHAT is posed to give us more information on the extent to which total mortality and CAD events will be reduced in women and the elderly.

So, what is the common sense attitude about cholesterol? I say, protect yourself, your family, friends, and patients with proven therapy against a known killer. Protection from the condition most likely to cause premature death and disability makes sense to me.

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