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By Melissa Tennen, HealthAtoZ writer
Many people diagnosed with coronary heart disease (CHD) are not getting their cholesterol down to recommended levels, which could complicate their already precarious health conditions.
A recent study found 60 percent of those treated with cholesterol-lowering drugs are not reaching the goals recommended in 2001 by the National Cholesterol Education Program. The results of this study were presented at the 75th Annual Scientific Sessions of the American Heart Association.
The number of people not getting enough treatment increased from 2.7 million in the 1990s to 3.2 million in 1999, the research found.
Why?
Those at high risk for heart attack and stroke may not understand the importance of lowering cholesterol for their cardiovascular health, according to experts. Therefore people may not be as attentive to cholesterol health as they are with other conditions.
"People know it's important, but they don't think it's urgent," says Christie M. Ballantyne, M.D., F.A.C.C., F.A.C.P., director of the Center for Cardiovascular Disease Prevention and professor of medicine at Baylor College of Medicine/The Methodist DeBakey Heart Center in Houston.
The only way to know if cholesterol level is off kilter is to check through a blood test.
Insufficient alarm
"If you have chest pain, that's alarming. But if your cholesterol is high, that is not so alarming," he says. "If your husband were in his 40s and he has a heart attack, how would you feel if you found that it could have been prevented? Controlling your cholesterol can cut the risk of a first or second heart attack."
Cholesterol-reducing drugs lower the levels of cholesterol in your blood stream. High levels of these cholesterol fats can increase the risk of hardening of the arteries, heart attack, stroke and other cardiovascular conditions.
Just because the doctor tells people to take a medication doesn't mean that the person will follow the instructions.
Sometimes patients may have an unwarranted fear of side effects. Many cholesterol-reducing drugs have side effects such as heartburn, indigestion, belching, bloating, gas, nausea or vomiting, stomach pain, dizziness, muscle aches and headache. These usually go away as the body adjusts to the drug and these side effects usually do not need medical treatment. If symptoms persist, your doctor may need to change your medications.
Another issue is that patients don't like being put on too many medications, Ballantyne says. And making multiple visits to the doctor is an inconvenience.
Treatment for high cholesterol levels usually begins with changes in daily habits. By losing weight, stopping smoking, exercising more and reducing the amount of saturated fat and cholesterol in the diet, many people can bring their cholesterol levels down to acceptable levels. However, some may need to use cholesterol-reducing drugs.
"People think it isn't as important, that treatment can be delayed," he says. "They say to their doctors, 'I feel okay. I'm feeling good, I've got my blood pressure down. Couldn't this wait?'"
Americans know better. But helping patients understand that cholesterol needs to be properly controlled is a beast that doctors wrestle with all the time. A recent American Heart Association survey found that although most people older than 40 know it's important to have healthy cholesterol, more than half did not know their own levels or even what the recommended levels are.
Denial at work
"It's not that they don't understand the risks, but they keep their heads in the sand. They don't want to take control. They want someone else to take control for them," says Michael H. Davidson, M.D., F.A.C.C., F.A.C.C.P., president and chief executive officer of the Protocare Trials Chicago Center for Clinical Research and director of Preventive Cardiology at Rush-Presbyterian-St. Luke's Medical School in Chicago. "But it has to be a partnership between the patient and the physician."
Once a traumatic event such as a heart attack or stroke roars into a person's life, they pay more attention to those cholesterol numbers.
"We are all immortal until we get sick," says Stephen Smith, M.D., director of inpatient cardiology services at the Henry Ford Heart and Vascular Institute in Detroit. "Most people who have had a heart attack do survive. At that point, it's usually not too hard to get them to change."
Everyone has cholesterol. Cholesterol plays important roles in the structure of cells and the production of hormones. But too much cholesterol in the blood can lead to heart and blood vessel disease.
Good, bad, total
Two types of cholesterol can be found in the body. One is called high-density lipoprotein (HDL) cholesterol, or "good cholesterol," which lowers the risk of these cardiovascular problems. The other type, known as low-density lipoprotein (LDL) cholesterol, or "bad cholesterol," threatens people's health. These names reflect the way cholesterol moves through the body. To travel through the bloodstream, cholesterol must attach itself to a protein. The combination of a protein and a fatty substance like cholesterol is called a lipoprotein.
In general, total cholesterol should be less than 200 mg/dL, which reduces the risk for heart attacks. Levels from 200 to 239 are considered borderline high, and 240 or more indicates a high risk.
LDL should be lower than 160 mg/dL if you have one risk factor such as high blood pressure. If you have two or more risk factors, LDL should be lower than 130 mg/dL. People at high risk or have known CHD or diabetes should have levels lower than 100 mg/dL. HDL should be higher than 40 mg/dL and triglycerides less than 150 mg/dL.
Doctors interpret cholesterol levels based on guidelines set by the National Cholesterol Education Program, which offer ways to best treat cholesterol problems and how to help reduce the risk of cardiovascular complications and death. These guidelines were released in 2001 by the Adult Treatment Panel III.
Not only do doctors look at cholesterol levels, but they also weigh risk factors such as family history of heart disease, your age, your blood pressure, smoking habits and blood sugar among others. With such information, they can estimate your risk for a heart attack in the next 10 years. High LDL levels cholesterol coupled with low HDL only adds to this potent mixture.
For a person whose only risk factor is high cholesterol, a doctor would simply urge them to eat better and exercise first. But for others, medications need to bolster the efforts to reduce cholesterol. And that is another aspect of under-treatment: following dietary and exercise advice.
License to eat
"People come into the doctor, get placed on lipid-lowering cholesterol drugs and they don't think about diet and lifestyle modifications. They think that since they are on a cholesterol-lowering drug, that it's carte blanch to eat whatever they want because they are on a medication," Smith says.
But doctors are also pressed against a clock. In today's medical culture of hurry-up doctor visits, physicians may not have the time they need to coach a patient.
"I think doctors do sometimes fail the patients. But in a 15-minute office visit, there is no way you can get all you need to talk about diet. It would take about an hour just to discuss diet," Smith says.
The message? It's up to the patient to take control.
Types of medication
Here are the types of medications that might help lower LDL levels and raise HDL.
Cholesterol absorption inhibitors: This is a new class of drugs that work best with statins to lower cholesterol by lowering the intestinal absorption of cholesterol. The drug ZetiaŽ (ezetimibe) is the first in this class and was approved in 2002 by the Food and Drug Administration. Using the combination treatment, 72 percent of statin-treated patients using ezetimibe reached recommended levels compared with an add-on placebo, or sugar pill. And ezetimibe working with statins provided 15-20 percent additional LDL cholesterol reduction compared to 4 percent with an addition of a placebo. The most commonly reported side effect of ezetimibe included back pain and arthralgia, which is pain in a joint.
Statins: These drugs are the first choice in treating high LDL levels. They work in the liver to prevent the formation of cholesterol. Statins are best at lowering LDL levels but also have modest lowering effects of triglycerides and raising HDL levels. Examples of statins include LipitorŽ (atorvastatin), LescolŽ (fluvastatin), MevacorŽ (lovastatin), PravacholŽ (pravastatin), rosuvastatin (CrestorŽ) and ZocorŽ(simvastatin). Statins may damage the liver or muscles. Patients who take the drugs should have blood tests to check for liver damage as often as their physician recommends. Any unexplained pain, tenderness or weakness in the muscles should be reported immediately to the doctor.
Niacin: Niacin (nictotinic acid) is a water-soluble B vitamin, which improves all lipoproteins when given in doses much higher than the standard recommended daily allowance. Nicotinic acid lowers total cholesterol, LDL-cholesterol and triglyceride levels while raising HDL-cholesterol levels. There are three types: immediate release, timed release and extended release. Most experts recommend starting with the immediate-release form. Nicotinic acid is inexpensive and widely accessible to patients over-the-counter (OTC) but must not be used for cholesterol lowering without a doctor monitoring you because of the potential side effects, especially liver damage. (Nicotinamide, another form of the vitamin niacin, does not lower cholesterol levels and should not be used in place of nicotinic acid.) Nicotinic acid reduces LDL levels by 10 percent to 20 percent, reduces triglycerides by 20 percent to 50 percent and raises HDL by 15 percent to 35 percent. A common and troublesome side effect of nicotinic acid is flushing or hot flashes, which are the result of blood vessels opening wide. Examples include the OTC form Slo-Niacin (polygel extended release niacin) and the prescription form NiaspanŽ (extended release niacin). Other side effects of niacin include stomach pain, nausea and vomiting and a rise in uric acid levels that can cause gout.
Statin and niacin combination: A combination medicine that contains a statin and niacin in a dose. This is available as AdvicorŽ (Kos).
Fibrates: The fibrates are primarily effective in lowering triglycerides and, to a lesser extent, in increasing HDL-cholesterol levels. Gemfibrozil, the fibrate most widely used in the United States, can be very effective for patients with high triglyceride levels. However, it is not very effective for lowering LDL-cholesterol. It is used in some patients for whom a goal of treatment is lowering triglycerides. Examples include LopidŽ (gemfibrizol) and TricorŽ (fenofibrate). The drug may cause gallstones or muscle problems. Patients taking gemfibrozil should check with a physician immediately if any of these side effects occur:
- Fever or chills
- Severe stomach pain with nausea and vomiting
- Pain in the lower back or side
- Pain or difficulty when urinating
- Cough or hoarseness
Bile acid sequestrants: These drugs bind with bile acids in the intestines and are eliminated in the stool. The usual effect of bile acid sequestrants is to lower LDL levels by 10 percent to 20 percent. Small doses of sequestrants can produce useful reductions in LDL. Bile acid sequestrants are sometimes prescribed with a statin to increase cholesterol reduction. When these two drugs are combined, their effects are added together to lower LDL by more than 40 percent. Cholestyramine, colestipol and colesevelam are the three bile acid sequestrants. They are not absorbed from the gastrointestinal tract, and more than 30 years of experience with the sequestrants indicate that long-term use is safe. Examples include QuestranŽ (cholestryamine), ColestidŽ (cholestipol) and WelcholŽ (colesvelam). Bloating and constipation are the most common side effects.
This article was reviewed and updated June 2007.
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