Cholesterol Lowering is Still Important

In the last several months there has been some bad press about cholesterol-lowering drugs. The ENHANCE trial is at the forefront of this controversy. This trial has been overblown in my opinion with regards to the importance of lipid lowering. I am asked almost daily by patients if they need to still keep taking medicine to lower cholesterol. In all honesty, if a patient has made it to the cardiac cath lab and I am putting a stent in them, it's a little too late.

The proverbial cart is out of the barn. The lowering of cholesterol has seen a profound impact is on the reduction of recurrent coronary events, such as repeat heart attack, stoke, and death in patients that have had a heart attack. Studies have been published that demonstrate a reduction in the rate of progression of atherosclerosis and a reduction in rate of first heart attack or admission to the hospital for chest pain in patients at risk for heart attack. These studies form the basis for what is know as primary prevention (treatment intended to stop the first clinical event such as heart attack or stroke).

The ENHANCE trial investigated a subset of patients that have a genetic abnormality that causes severe elevation in cholesterol levels. These patients have a dramatically increased risk of heart attack. Patients were treated with the combo pill Vytorin (ezetimbe/simvatatin) the endpoints of this trial were difficult to analyze for the investigators and difficult to interpret for physicians. The concept that after this trial that the lowering cholesterol is not as beneficial as we once thought is absurd in my opinion. What patients need to know is that this trial did not have any of the long term data that clinicians look for to signal the treatment choice was efficacious. The lowering of cholesterol in this study did not impact on the thickness of the carotid artery in this population. There was not enough long term follow up or a large enough cohort of patients to provide information on the reduction of heart attack.

For now, I recommend for my patients that have coronary artery disease with either a stent or bypass surgery that they take the statin that will help them reach the goal levels recommended by the American College of Cardiology and the National Cholesterol Education Program. Patients that have diabetes, Peripheral Arterial Disease, and chronic kidney disease are a high risk group that should be treated as if they already have significant coronary artery disease with very aggressive lowering of cholesterol.

For patients with minimal risk factors lifestyle modification with a focus on diet and exercise is the cornerstone of treatment and is the first line of treatment.