Cholesterol. How low should we go?

The National Cholesterol Education Program NCEP has recently updated their Adult Treatment Panel (ATP) III guidelines and called for more intensive cholesterol treatment, especially in patients at high risk for coronary heart disease CHD. The message from the updated report is that lower is better for high risk patients, with the NCEP expert panel calling for low-density lipoprotein LDL- cholesterol treatment targets of <100 mg/dL in patients at high risk for CHD. In very high risk patients, however, aggressively lowering LDL-cholesterol to <70 mg/dL is now a therapeutic option for clinicians. Very high risk individuals are those with cardiovascular disease plus diabetes, persistent cigarette smoking, poorly controlled hypertension, or multiple risk factors of the metabolic syndrome, and those who recently had a myocardial infarction MI. Despite the strong clinical evidence and widely publicized treatment guidelines, many hyperlipidemic patients receive inadequate lipid-lowering treatment or leave the hospital after having a MI without a statin. Intensive therapy should be considered for all patients admitted to the hospital for acute coronary syndrome. Achieving very low levels of LDL-cholesterol often requires high doses of a statin or a combination therapy. The coadministration of ezetimibe, a new cholesterol-absorption inhibitor, further reduced LDL-cholesterol by 23% compared with those patients who remained on statin therapy alone. Recent trials with statin therapy are discussed in this review.