A study in the Feb. 28 Archives of Internal Medicine reveals that only a fraction of people with elevated blood cholesterol levels are receiving adequate treatment.

The study authors, led by Thomas A. Pearson, M.D., from the University of Rochester School of Medicine, used data obtained from the multicenter Lipid Treatment Assessment Project, or L-TAP, to determine what percentage of patients who were receiving lipid-lowering therapy for elevated “bad” cholesterol (LDL-C) actually achieved treatment goals.

These goals were last outlined in 1997 by the National Cholesterol Education Program, which was established by the federal National Institutes of Health in 1983. The NCEP periodically issues revised cholesterol guidelines.

The almost 5,000 study patients were divided into three groups:
Low risk of heart disease, having less than two known risk factors for coronary artery disease, or CAD, and no history of the disease;
High risk of heart disease, having two or more risk factors, but no apparent CAD; and
Those with known CAD. CAD was diagnosed in those who had a history of heart attack, or had bypass surgery or angioplasty.

CAD risk factors include smoking, high blood pressure, diabetes, age, low “good cholesterol” (HDL-C), and family history of premature CAD. The study evaluated equal numbers of men and women, and the patients’ average age was 60.

The NCEP-recommended treatment goals for group-1 patients was less than 160 milligrams of LDL-C per deciliter; for group 2, it was less than 130 milligrams per deciliter; and for group 3, less than 100 milligrams per deciliter.

Surprisingly, only 18 percent of those with known CAD (group 3) were being treated with enough medication without a prescription to lower their LDL-C to the NCEP-recommended level. In group 2, only 37 percent of these high-risk patients had levels of 130 milligrams per deciliter or less, while in the low-risk group 1, the level of 160 milligrams per deciliter was attained in 68 percent. Overall, the success rate was 38 percent.

The success rate was higher in those patients who were treated with prescription drugs as opposed to diet alone, but was highest in those treated with both diet and drugs. Those who were treated with “statin” drugs had a greater rate of achieving NCEP goal levels of LDL-C than those who were treated solely with other drugs. The majority of physicians responsible for prescribing treatment for the study patients said they were aware of the NCEP guidelines, and they knew that lowering LDL-C was an important treatment approach to CAD prevention.

Why then is there such a low level of successful treatment for this very treatable condition? The drugs used most commonly and effectively, the statins, are generally quite safe and easily tolerated. It has been clearly established that cholesterol-lowering therapy reduces the occurrence of both initial and recurrent coronary events. Several studies over the past few years have yielded similar results: not enough is being done to lower elevated cholesterol levels.

The study authors have no easy answer, but theorize that one or more of the following factors may explain this situation: too low a dosage of drug, low drug efficacy, wrong choice of drug, and noncompliance with the prescribed regimen.

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