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Cholesterol in patients with coronary heart disease: how low should we go?
1Department of Medicine, Veterans Affairs Medical Center, Minneapolis, Minnesota 55417, USA.
Insights
Evidence for aggressively managing low to moderate cholesterol in coronary heart disease (CHD) patients is limited. Current recommendations lack convincing efficacy data, contrasting with high cholesterol management. Consider therapy risks versus uncertain benefits.
Area of Science:
- Cardiovascular Medicine
- Clinical Trials
- Evidence-Based Practice
Background:
- Recent guidelines recommend aggressive cholesterol management for coronary heart disease (CHD) patients with low to moderate cholesterol levels.
- The efficacy of this recommendation requires thorough examination.
Purpose of the Study:
- To critically review the scientific evidence supporting the aggressive management of low to moderate cholesterol levels in patients with established coronary heart disease (CHD).
Main Methods:
- Systematic review of cohort studies and clinical trials.
- Studies included CHD patients with low to moderate cholesterol levels and angiographic or clinical endpoints.
- MEDLINE database search was utilized.
Main Results:
- Cohort studies did not demonstrate a significantly increased risk of CHD death with moderate cholesterol levels, though a slight excess risk is suggested (pooled RR 1.14).
- Two of five angiographic trials showed no benefit from intensive lipid-lowering therapy in CHD patients with moderate cholesterol.
- Other trials were confounded by additional interventions; no large clinical trials with clinical endpoints exist for this patient group.
Conclusions:
- The recommendation for treating low to moderate cholesterol in CHD patients lacks convincing evidence of efficacy.
- This contrasts with high cholesterol management in CHD, which has strong evidence of benefit.
- Clinicians and patients should weigh potential therapy disadvantages against uncertain benefits pending further trial results.
Clinical Problem:
To examine the evidence supporting the recent National Cholesterol Education Program (NCEP) recommendation that low to moderate levels of cholesterol should be aggressively managed in patients with coronary heart disease (CHD).
Methods:
Cohort studies and clinical trials with angiographic or clinical endpoints, that included CHD patients with low to moderate levels of cholesterol, were systematically identified through a MEDLINE search and critically reviewed.
Synopsis:
None of the cohort studies show that a moderate level of cholesterol confers significantly increased risk of CHD death, although a pooled relative risk of 1.14 (95% CI 1.08 to 1.4) suggests that there may be a slight excess risk. Of five angiographic trials of CHD patients with moderate levels of cholesterol, two demonstrated no improvement in angiographic endpoints with intensive lipid-lowering therapy and the other three are difficult to interpret since they included other interventions in addition to the cholesterol-lowering regimen. No large clinical trial with clinical endpoints has been reported for CHD patients with low to moderate levels of cholesterol.
Recommendations:
The recommendation to treat CHD patients who have low to moderate levels of cholesterol with diet or drugs is not based on convincing evidence of efficacy. This is in clear contrast to the recommendation for CHD patients with high levels of cholesterol, for whom there is definitive clinical trial evidence of benefit from cholesterol-lowering therapy. While we await clinical trial results for CHD patients with low to moderate levels of cholesterol, clinicians and patients must consider the possible disadvantages of therapy in relation to the uncertain benefit.