Are we soon to see a relaxing in cholesterol guidelines?

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What is deemed a desirable cholesterol level in the mind of many health professionals has a lot to do with the opinion of panels of ‘experts’ who, essentially, tell doctors what to think and how to manage their patients. One such endeavour in the US is known as the Adult Treatment Protocol (ATP), which itself is part of the National Heart, Lung and Blood Institute. The ATP has seen three versions, the last of which (ATP III) was published in 2002 and updated in 2004. The message from ATP III was loud and clear – individuals should strive to lower their cholesterol levels to reduce their risk of cardiovascular disease.

ATP IV is due later this year. According to this report in the journal Nature, there may be relaxing of the rules on cholesterol management. The piece draws attention to some key deficiencies in current cholesterol policy.

Firstly, the idea that ‘lower is better’ has not been formally tested. It’s actually based on assumptions. And these assumptions come from studies that were never able to determine whether getting cholesterol levels down to a certain level is better for patients than other levels. In fact, it’s been previously noted in the scientific literature that the idea of treating people according to predetermined cholesterol levels is not founded in science at all [1].

The greatest assumption of all made in the current recommendations is that reducing LDL-cholesterol (supposedly ‘unhealthy’ cholesterol) levels translates into a reduction in risk of cardiovascular disease. However, just plain logic dictates that just because something reduces cholesterol levels does not mean it must be beneficial for health. Eating coal or swigging back arsenic might, for all we know, be wonderful cholesterol-reducing strategies, but it’s obvious they would unlikely bring us better health.

In the piece we learn of research which found that more aggressive drug treatment for diabetes brought worse outcomes for patients. It’s worth bearing in mind we have seem similar things with cholesterol, where drugs that ‘improve’ blood fat levels (such as torcetrapib) have been found to increase the risk of heart attacks and death. We also continue as doctors to prescribe cholesterol-modifying drugs such as ezetimibe even though no evidence to date has found it brings benefits for health, and some evidence links it with an increased risk of cancer.

The news piece quotes Yale University cardiologist Harlan Krumholz, who says: “We can’t just assume that modifying the risk factor is modifying risk,” Professor Krumholz believes that LDL-cholesterol targets should be abandoned, because they have never been test properly tested. And he’s not the only one who is skeptical. Here’s an excerpt from the article:

Jay Cohn, a cardiologist at the University of Minnesota Medical School in Minneapolis, also worries that the focus on LDL levels offers up the wrong patients for statin therapy. Most of those who have a heart attack do not have high LDL, he notes. Cohn advocates treating patients with statins based on the state of health of their arteries, as revealed by noninvasive tests such as ultrasound. “If your arteries and heart are healthy, I don’t care what your LDL or blood pressure is,” he says.

Against these opinions, though, we have the might of the pharmaceutical industry. We know from experience that this business has a history of grooming and paying ‘key opinion leaders’ to work on their behalf. No doubt, I think, there will be some such influence on the ATP panel.

However, what is heartening is that this issue is being discussed at all. Against the relentless tide of information which persuades us of the merit of cholesterol reduction, its good to see at least some doctors think for themselves and with a clear head.


1. Hayward RA, et al. Narrative review: lack of evidence for recommended low-density lipoprotein treatment targets: a solvable problem. Ann Int Med 2006;145:520-530[hr]

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