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October 18th, 2012

Should Hypercholesterolemia Treatments Start Much Sooner in Life?

Keeping LDL cholesterol low throughout life is more effective at preventing atherosclerotic disease than starting statins in middle age, a series of analyses in the Journal of the American College of Cardiology shows.

Researchers first established the effects of several genetic variations on naturally lowering LDL. People with one or more of these variants had their risk for coronary heart disease reduced by over half for each 40 mg/dL reduction in long-term exposure to LDL, relative to those without the variants. Next, researchers found that trials of statin therapy, participation in which usually begins later in life, had a much lower risk reduction — about 25%.

Editorialists say that the analyses, in their view, justify “acting without waiting” for a randomized trial. They recommend focusing on lifetime risk — as opposed to the 10-year risk window of the Framingham risk score — and starting lifestyle changes or drug treatment much sooner.

Reprinted with permission from Physician’s First Watch

Categories: Prevention
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7 Responses to “Should Hypercholesterolemia Treatments Start Much Sooner in Life?”

  1. Enrique Guadiana, Cardiology says:
    October 18, 2012 at 7:04 pm

    I don’t see any problem starting early lifestyle changes. Many heath problems came from unhealthy lifestyles. About drug intervention, first it is necessary to explore the risk from long time treatment and the cost/benefit. Don’t forget the alteration in glucose metabolism and statin treatment controversy for example.

  2. Antonio Reis, Ph.D says:
    October 19, 2012 at 4:53 pm

    Unfortunately Mother Nature was not smart enough to develop statins in our bodies to fight the ugly cholesterol.

    See HUNT 2 Study at
    http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2753.2011.01767.x/pdf
    Surprised?

  3. Uffe Ravnskov, MD, PhD says:
    October 20, 2012 at 5:47 am

    To calculate the risk in this way is highly questionable by several reasons. Many cohort studies have shown that high LDL-cholesterol is not a risk factor for women (1), for old people (2-9) or for diabetics (10-16) and in a meta-analysis of 14 cohort studies including all ages, LDL-C was not a risk factor in five of the studies (17) Furthermore, most statin trials have shown that the effect is the same, whether the initial LDL-cholesterol is high or low. Recently two studies have shown that LDL cholesterol in patients with acute myocardial infarction is lower than normal (18,19). In one of them a three-year follow-up of the patients showed that more than twice as many had died among those with the lowest LDL-cholesterol. In accordance with this finding is the result from the 30-year follow-up of the Framingham study. To cite the authors: ”For each 1 mg/dl drop of cholesterol there was an 11 percent increase in coronary and total mortality.”

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  4. Uffe Ravnskov, MD, PhD says:
    October 20, 2012 at 6:15 am

    The reference to the Framingham study mentioned above is no. 20

  5. Dan Hackam, MD PhD says:
    October 20, 2012 at 2:54 pm

    Of course lipid modification needs to be started early. The question is how to do it. Outside of FH and other inherited diseases, lifestyle modification remains key for the young. The earlier we start, the better the long-term outcomes, and the bigger the eventual cost-savings. We must inculcate healthy food choices – a reduction in carbohydrates, an increase in non-starchy vegetables, and substitution of plant-based fats and oils for animal-based saturated fats and dietary cholesterol.

  6. William L Blanchet, MD says:
    October 21, 2012 at 1:15 am

    The leap of logic in the conclusion of this study does not pass the straight face test. Seriously, an intelligent researcher could conclude that the genetic variables associated with lower LDL and lower MI rates can be used to justify earlier use of statin drugs!

    If that logic had value, we would find greater improvement in outcomes the longer a statin trial lasts. This is not the case. All trials taken to longer term endpoints tend to show diminishing results from longer term statin use compared to the shorter term outcomes.

    I have a much greater fear of the long term consequences from statin toxicity than whatever theoretical benefit might be achieved in treating people without disease.

    The well referenced comments by Dr. Ravnskov should silence further discussion.

  7. Jacques Barth, MD, PhD says:
    November 5, 2012 at 4:40 am

    of course earlier the better. Why dont we monitor everybody with a carotid intima media thickness assessment? seems like the obvious choice