Cholesterol reduction is beneficial


My doctor has advised me to take medication to lower my cholesterol, which has always been around 280 despite plenty of exercise and a low-fat diet. Why should I start on a drug when at age 55 I have no symptoms of heart disease, my electrocardiogram is normal, and there are significant risks, side effects and costs of medications to lower cholesterol?

There are two reasons why you should follow your doctor's advice:

1. Population studies have shown that men with cholesterol levels like yours have a three times greater risk of dying of a heart attack than men with cholesterol levels around 200.

2. A study of men without evidence of heart disease, published in the New England Journal of Medicine in mid-November, showed that lowering cholesterol levels with a drug reduced the likelihood of having a heart attack and of dying of any cause during the 4.9 years of the study.

This study included 6,600 men in Scotland who were between 45 and 64 years of age, had an average cholesterol level of 272 and no history of coronary heart disease. Subjects were randomly assigned to receive a placebo or the cholesterol-lowering drug pravastatin.

During an average follow-up period of 4.9 years, the cholesterol fell by 20 percent in the pravastatin group and did not change in the placebo group. Compared with those on placebo, the pravastatin group had a 31 percent reduction in the risk of heart attacks and deaths from coronary heart disease.

Also, those treated with pravastatin had a 22 percent decrease in overall mortality during the study period, as well as 37 percent fewer angioplasty and coronary artery bypass procedures.

Despite newspaper articles that emphasized the concerns of some researchers that lowering cholesterol increases the risk of death from cancer and other diseases, this study saw no increase in deaths from cancer or any other cause in the group receiving pravastatin.

Similar results were obtained in an earlier Scandinavian study of 2,220 individuals with known heart disease who had a decreased overall mortality, compared to a placebo-treated group, and no increase in deaths from other causes while taking another cholesterol-lowering drug (simvastatin) over a 5 1/2 -year period.

Although these medications can produce side effects, they are uncommon. In fact, in these two studies, subjects taking the placebo had the same incidence of side effects as those taking either pravastatin or simvastatin. While earlier studies had shown that lowering cholesterol reduced the number of heart attacks and other coronary events in men free from coronary heart disease, the Scotland study is the first to find a fall in overall mortality in such men.

Unfortunately, no women were included in this study, and the Scandinavian study showed a reduction of coronary events, but no decrease in the overall mortality rate in women. So evidence for the benefits of lowering cholesterol in women is not as strong as for men.

Dr. Margolis is professor of medicine and biological chemistry at the Johns Hopkins School of Medicine.

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