Dr. Ben Wedro practices emergency medicine at Gundersen Clinic, a regional trauma center in La Crosse, Wisconsin. His background includes undergraduate and medical studies at the University of Alberta, a Family Practice internship at Queen's University in Kingston, Ontario and residency training in Emergency Medicine at the University of Oklahoma Health Sciences Center.
Dr. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. He has a PhD in Microbiology (UT at Austin), and the MD (Univ. Texas Medical Branch, Galveston). He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.
Controlling blood cholesterol levels may decrease the risk of heart attack
and stroke. The National Institute of Health, the American Heart Association and
the American College of Cardiology publish guidelines to help physicians and
patients with this risk reduction. The most recent consensus in 2004 recommended
Consider more intensive LDL cholesterol-lowering for people at very high, high, and moderately high risk for a heart attack. For
example, for patients with a very high risk of heart attacks, the LDL cholesterol treatment goal remains at <100mg/dl, but the report advised doctors to consider
the option of lowering the LDL cholesterol (usually using a statin plus
lifestyle changes) to <70 mg/dl.
Initiate therapeutic lifestyle changes to modify lifestyle-related risk
physical inactivity, metabolic syndrome, high blood triglyceride levels and
low HDL cholesterol levels). Lifestyle changes have the potential to
reduce heart attack and stroke risks through several mechanisms beyond the
lowering of LDL cholesterol.
When LDL-lowering medication is used for very high,
high or moderately high risk patients, the report advises that the intensity
of LDL-lowering drug therapy be sufficient to achieve at least a 30 to 40
percent reduction in LDL cholesterol levels.
When a very high or high risk patient also has high
blood triglyceride or low HDL cholesterol levels, doctors may consider
combining nicotinic acid or a fibrate with a statin. Nicotinic acid and
fibrates are more effective than statins in lowering triglycerides and
Age should not be a consideration since
older persons also benefit from lowering LDL cholesterol. It is never too
late or the patient too old to begin lifestyle changes and medications to lower
LDL cholesterol. A word of caution is in order. Elderly patients are more likely
to have liver and kidney dysfunction, and are also more likely to be on multiple
medications some of which may interfere with the breakdown of
cholesterol-lowering drugs such as statins. Thus lower dosing may be necessary
to avoid adverse side effects.
The 2004 NCEP treatment goals according
to risk categories
More intense LDL goal option
Initiate TLC if LDL is:
Consider drugs + TLC if LDL is:
Very high risk
Moderately high risk (10 yr. risk 10%-20%)
drug option if LDL is 100-129 mg/dl
Moderate risk (10 yr. risk <10%)
>190 mg/dl, consider
drug optional if LDL is 160-189 mg/dl
High risk patients are those who already
have coronary heart disease (such as a prior heart attack), diabetes mellitus,
abdominal aortic aneurysm, or
those who already have atherosclerosis of the arteries to the brain and
extremities (such as patients with strokes, TIA's (mini-strokes), and
peripheral vascular diseases). High risk patients also include those with 2 or
more risk factors (for example, smoking,
hypertension, or a family history of early
heart attacks) that places them at a greater than 20 percent chance of having
a heart attack within 10 years. (A person's chance of having a heart attack
can be calculated by using the Framingham Heart Study Score Sheets, at http://nhlbi.nih.gov/about/framingham/riskabs.htm).
high -risk patients
are those who have coronary heart disease in addition to having either
multiple risk factors (especially diabetes), or severe and poorly controlled
risk factors (such as continued smoking), or metabolic syndrome (a
constellation of risk factors associated with obesity, including
triglycerides and low HDL). Patients hospitalized for acute coronary syndromes
are also at very high risk.
Moderately high risk
patients are those who have neither coronary heart disease nor diabetes
mellitus, but have multiple (2 or more) risk factors for coronary heart
disease that put them at a 10 to 20 percent risk of heart attack within 10
years. (Use the Framingham Heart Study Score Sheets, at
http://nhlbi.nih.gov/about/framingham/riskabs,htm to calculate the 10 year
Moderate risk patients
are those who have neither CHD nor diabetes mellitus, but have 2 or more risk
factors for coronary heart disease that put them at a <10% risk of heart
attack within 10 years.
patients are those with 0 to 1 risk factor for coronary heart disease.