Americans are obsessed with high cholesterol. Probably because most of us have it. Most of us know that high cholesterol can lead to heart attacks, strokes and other bad things.
However, cholesterol is just one of many risk factors. Half of the heart attacks in this country happen in people with normal cholesterol. AND, if you don’t have other risk factors, treating your cholesterol has smaller benefits than most people expect.
We will start with the benefits and risks of treatment and then move to the details of what is currently recommended.
The Benefits
We know that having a high cholesterol, a low HDL, high triglycerides or a high LDL increases the risk of a heart attack. However, changing these numbers with drugs may or may not improve the risk.
Statins
We know that using a statin drug like simvastatin, pravastatin, lovastatin, or atorvastatin will decrease this risk by about 30%. This is a significant benefit, but it may not be as big as it seems. It depends on how high your risk is to begin with. Scroll to the bottom to see the risk tables. If you have read our review of one of these drugs you have already seen them.
Other Cholesterol Drugs
Other cholesterol drugs have not shown very much benefit in preventing heart attacks or death. This includes cholestyramine, colestipol, niacin, Niaspan, gemfibrozil, fenofibrate. Remember that improving numbers may not decrease risk. There was a drug called torcetrapib that increased the HDL (healthy cholesterol) dramatically. It should have decreased heart attacks dramatically, but when it was studied, the opposite happened.
Women
Amazingly, for women with high cholesterol who have not yet had heart disease, there benefit has never been proven and is probably VERY small (like a decreasing the risk of a heart attack from 3 out of 100 to 2 out of 100 over ten years.
Triglycerides (a special case)
Note that very high triglycerides(over 800mg/dl or9 mmol/L) can cause pancreatitis and other bad effects besides heart attacks. They should be treated with gemfibrozil or fenofibrate if they do not improve with lifestyle modifications or better blood sugar control in diabetics.
Guidelines
The current medical guidelines in the U.S. recommend aggressive treatment of cholesterol based on the LDL level. However, when people with high cholesterol are told the actual amount of benefit they will receive, we suspect many will opt to not take the cholesterol medication. Remember, the lower your risk, the lower the benefit. The higher your risk, the higher your benefit. Click for a summary of National Cholesterol Education Program (NCEP) Treatment Guidelines
So What is Your Risk and Benefit?
Low to Moderate Risk People
| Framingham calculated 10 year heart attack risk | Estimated risk if you take simvastatin |
| 20% | 14% |
| 15% | 10% |
| 10% | 7% |
| 7% | 5% |
| 4% | 3-4% |
High Risk People (those with a recent heart attack)
| Events in 4 years of treatment | Sugar Pill | Simvastatin |
| Heart Attacks | 28% | 19% |
| Deaths | 12% | 8% |
If you have diabetes, your risk is thought to be at least 20% risk in the next 10 years.
