Q: I had a heart attack this fall and was put on a diet for lower cholesterol. It remains slightly elevated, but my doctor hasn't given me any medicine to lower my cholesterol because he isn't convinced that will prolong my life. Do you agree, or do you believe I should take a medicine to decrease my cholesterol further?
A: Several early, long-term trials showed that lowering the cholesterol over a period of five to seven years reduced the number of coronary events, such as a heart attack or the #F development of angina, in men who had no indication of coronary artery disease (CAD) when they entered the trials. However, the men taking a cholesterol-lowering drug in these trials did not live any longer than individuals taking a placebo. Indeed, some critics of the recommendations to lower cholesterol have argued a reduction may be accompanied by an increase in deaths from other causes, especially cancer and violence (suicide, accidents, murder).
More than 10 studies have shown that lowering cholesterol for two to four years in men and women with proven CAD slows the progression of narrowings in the coronary arteries, decreases the appearance of new narrowings, slightly widens some of the narrowed places, and diminishes the number of coronary events. There was no prolongation of life in these trials, either.
A Scandinavian study of 4,444 subjects published last November has shown that lowering cholesterol in men and women with proven CAD does lengthen life as well as reduce the number of coronary events. Subjects in this trial were followed for an average 5.4 years while taking either a placebo or a HMG CoA reductase inhibitor to lower their cholesterol.
The medication also lowered their triglycerides. Those taking the cholesterol-lowering drug reduced their risk of CAD deaths by 30 percent, their risk of dying of any cause about 40 percent, and their risk of a major coronary event by 34 percent.
These risks were reduced in men and women in all adult age groups. The drug was well tolerated -- the incidence of side effects was similar in those taking the placebo and those on the drug.
I do not agree with your doctor. The Scandinavian trial provides convincing evidence that lowering cholesterol does prolong life in those with known CAD. It is still not clear whether long-term treatment prolongs life in those who do not have CAD.
Without knowing your cholesterol level, it is hard to answer directly whether you should be on a drug to lower cholesterol further. The generally accepted guidelines in this country recommend that people with known CAD have their LDL ("bad") cholesterol reduced to less than 100 ng/dL.
Dr. Margolis is professor of medicine and biological chemistry at the Johns Hopkins School of Medicine.