Don’t wait for a heart attack

Don’t wait for a heart attack – Prevention, part 1

Stephen E. Goldfinger

Nothing motivates people to bring down a high cholesterol level quite so effectively as a heart attack, and there’s ample evidence that when survivors successfully lower their lipids, the risk for a second event falls dramatically. Not only that, but in the long run these patients live longer than they otherwise would have.

But what about people with high cholesterol who haven’t had a heart attack? Although physicians have been advising them to bring down their cholesterol with diet, exercise, and drugs if needed, there was no real proof that this paid off. Now there is, thanks to a landmark report from Scottish researchers that appeared in the November 16, 1995, issue of the New England Journal of Medicine. This study showed that treatment with a lipid-lowering drug reduced heart disease deaths by 33% and improved overall survival by 22%, compared with rates for people given a placebo.

The 6,595 men recruited for the West of Scotland Coronary Prevention Study Group were 45 to 64 years old, with average total cholesterol of 272 mg(dl — below 200 is considered desirable — and an average low-density lipoprotein (LDL) level of 192 mg(dl -130 is desirable for those with other risk factors. Although none of these men had suffered a heart attack, they were not in the best of shape: 44% currently smoked, 15% had high blood pressure, and 5% reported angina (cardiac chest pain) within the past year.

Good numbers, big bucks

Participants were recruited from a larger group who had visited coronary screening clinics and been counseled about the benefits of a heart-healthy diet. After two months, those whose level of harmful LDL-cholesterol remained above 155 mg/dl were randomly assigned to take either 40 mg of pravastatin or an inactive pill each evening.

Pravastatin (Pravachol) is one of the newer HMG-CoA reductase inhibitors, a class of drugs that has become tremendously popular since the first one, lovastatin (Mevacor), was introduced in the late 1980s. Although they have few side effects and only need to be taken once a day, the trade-off is that these medications cost more than other common lipid-lowering agents. The pravastatin dosage used in the Scottish study costs roughly $120 a month in the United States.

Total cholesterol fell by 20% and LDL levels by 26% for men in the pravastatin group, whereas lipid values did not change for participants who took the placebo. The real bottom line, of course, is that after five years researchers documented a 33% reduction in cardiac deaths and a 22% decline in overall deaths for the men taking the drug. The news that overall mortality was lower with treatment was welcome, as several less rigorous investigations had hinted at an inexplicable rise in noncardiac deaths due to suicide, accidents, or cancer.

No easy answers

Drug companies will no doubt make the most of these results, promoting lipid-lowering pills as the easy alternative for people who can’t, or won’t, change unhealthy habits. And experts worry that consumers will demand drugs instead of making an effort to eat a healthier diet and get off their duff.

Although a drug like pravastatin obviously can reduce an elevated cholesterol level, it does not confer the benefits of regular exercise or a low-fat diet. Being physically active is essential for cardiovascular fitness, it’s a sensible method for controlling weight, and it helps people preserve the strength and mobility that is needed to stay independent late in life. Moreover, there is convincing evidence that exercise lowers the risk for cancers of the colon and breast, and some indication that it reduces the risk for other malignancies as well.

A healthy diet may have even more preventive value. People whose cholesterol worries motivate them to eat more vegetables and less fat are simultaneously reducing their risk for cancers of the bowel, breast, or prostate. More recently, researchers have found that there’s a strong association between consuming lots of saturated fat and the likelihood of losing one’s vision to age-related macular degeneration.

Even people who elect to take pravastatin or some other lipid-lowering drug have to watch what goes on their plate. If popping pills is viewed as a license for gorging on burgers and ice cream, levels of bad LDL-cholesterol are likely to stay right where they started.

Although the Scottish study was limited to men, there is no strong reason to believe that its results apply only to them. Women with elevated lipids probably will have fewer cardiac events and live longer if their levels are lowered with diet, exercise, or drugs. Treatment should be initiated on the basis of a measured excess of LDL-cholesterol, however, and not because total cholesterol appears high.

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