LDL Cholesterol is Not a Good Indicator of Heart Attack Risk

Half of all heart attacks occur in people with low, even optimal, LDL cholesterol as established by the National Cholesterol Education Program. 

Got your attention?

A not well-publicized fact that is becoming increasingly evident in cardiovascular disease research—by itself, LDL cholesterol is not a good indicator of heart disease risk.  So then why in the beegeebers is LDL the standard indicator that is consistently used by the medical profession across America, seemingly without question?  It follows that this one risk factor by which individuals and businesses measure their well-intentioned efforts to become healthy may not lead to the desired result, which I assume is to prevent heart attacks.  It’s not that LDL cholesterol should not be considered—it should.  What is debatable is if it should be the primary focus, often the only focus to the exclusion of other perhaps more important factors that lead people right to an unexpected heart attack. . .

So how is it that so many astute doctors just fall in line with the LDL cholesterol focus?  

Answer: the power of pharmaceutical companies and the fact that the “gold standard” report from the National Cholesterol Education Program entitled “Adult Treatment Panel III” published in 2001 (http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3full.pdf) identified LDL cholesterol as the “primary target of cholesterol-lowering therapy” and strongly linked it to cardiovascular disease.  But a closer look at the panel of experts who developed this report 11 years ago (to be subsequently dispersed to every physician) reveals heavy financial ties to the pharmaceutical industry (think statins) (http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3upd04_disclose.htm).  I am not assuming anything nefarious, but the fact that there are strong ties between the panel and numerous pharmaceutical companies lets us at least know the lens through which these reviewers see, whether it be credible professional support for cholesterol-lowering drugs or something less noble.  Even the studies which are cited as foundational to the panel’s conclusions raise questions.  For example, the panel reported that “The prevalence of elevated levels [of LDL] in large part accounts for the near universal development of coronary atherosclerosis in the United States and the high attendant risk for developing CHD over a lifetime—49 percent for men and 32 percent for women” (p. II-2 of the ATP III report), citing a study from 1999 (Lloyd-Jones DM, Larson MG, Beiser A, Levy D. Lifetime risk of developing coronary heart disease. Lancet 1999;353:89-92) in which between 19% and 49% of the participants were current smokers! (http://www.medicine.ox.ac.uk/bandolier/booth/hliving/LifeCHD.html).  It should be obvious that attributing LDL cholesterol “in large part” to the high risk for heart disease and then linking it in the same sentence to a study on prevalence of heart disease which included up to 49% smokers is irresponsible.  While evidence for LDL cholesterol as a factor in cardiovascular disease has been accumulating, the assumption that LDL is the primary risk factor (convenient to drug companies who have been promoting their cholesterol-lowering drugs) was not adequately challenged at the time of the report.  We are long overdue for a new review of the evidence.   National Cholesterol Education Program . . . where are you?

So now it is 2012, 11 years later, and we still have the one missive to all physicians and health professionals to focus first and foremost on LDL cholesterol.  Even if it was a legitimate conclusion of the expert panel in 2001 (which is debatable) because of the focus on LDL cholesterol and the type of evidence that had accumulated through that lens up to that time, strong evidence continued to accumulate over the next 11 years for many other risk factors which were already strongly identifiable at the time of the original report.  In fact it wasn’t long after the ATP III report was published that the emphasis on LDL cholesterol was questioned in the scientific community.  So especially now, at a time when many businesses are battening down the hatches in the current economic storm, establishing goals (and spending money) using a measure which is hotly debated as valid in producing the desired result (healthier employees) is at best wasting a lot of money, and at worst dangerously misleading people who are putting their trust in what their health professionals (and employers) are telling them to do.

So the rather mystifying and unwelcome fact (to the pharmaceutical industry) that 50% of all heart attacks occur in people with low LDL cholesterol necessarily got scooped up for different explanations (note that this fact is not even generally recognized by the public, which again goes to show the power of the interests that “educate” our common knowledge—all we need to know is that America has a problem with LDL cholesterol and the drug companies have the solution):

Explanation 1:  On the one hand, the evidence that cardiovascular disease is a multi-factorial disease, which at its root is a problem of inflammation, is strong and accumulating.  I will discuss the other factors which everyone should be aware of in future blogs (HDL cholesterol, triglycerides, insulin, blood pressure, the metabolic syndrome, C-reactive protein, homocysteine, lack of exercise, stress, lack of a varied diet—see what I mean about multi-factorial?).  But don’t be overwhelmed—a simple healthy diet and exercise can affect all of the risk factors.  The logical explanation for the 50% of all heart attacks which occur in individuals with low LDL cholesterol is that LDL as an indicator for the whole picture is missing the mark, dramatically.  Even the 2001 ATP III expert panel concluded that “The metabolic syndrome and its associated risk factors have emerged as a coequal partner to cigarette smoking as contributors to premature CHD”.  Even so, the panel still positioned LDL cholesterol as the “primary target of therapy”.  But as with any lucrative topic that is also on the forefront of America’s collective minds, others with a different incentive driven by pharmaceutical company interests also have an explanation for why 50% of all heart attacks occur in people with low LDL cholesterol—

Explanation 2:  The current cholesterol guidelines are just not low enough, say the pharmaceutical company interests.  Get ‘em lower!  And use more drugs to do it!  The problem with this explanation is there is no good evidence to support the claim that even lower LDL cholesterol translates to less cardiovascular disease.  There is, however, strong accumulating evidence for cardiovascular disease as a multi-factorial disease, and that modifying these risk factors through diet and exercise does indeed lower risk for hearts attacks. 

The problem with the National Cholesterol Education Program’s ATP III expert panel’s declaration that LDL cholesterol is the “primary target of therapy” is that many, if not most, health professionals and wellness coordinators will start and end with lowering cholesterol as the be-all and end-all to their financially constrained efforts to help their patients and employees prevent cardiovascular disease.  As we can see, that focus falls far short of the goal for everyone involved—50% short.

The National Business Group on Health, a non-profit association of 342 large employers providing health care coverage for more than 50 million U.S. workers, retirees and their families,  published the results of a survey in August 2012 of what employers are planning to do in the wake of the continuing health care crisis and the new health care reform law (Affordable Care Act).  In addition to increasing their employee’s cost-sharing, the survey found that employers, in their efforts to engage employees in healthy behaviors and lifestyles, continue to experiment with the best ways to incorporate financial incentives into wellness programs.  While nearly half of respondents (48%) use incentives to encourage participation in programs, some employers are basing incentives on specific health outcomes.  More than four in ten (44%) provide an incentive based upon tobacco-use while three in ten (29%) base awards upon achievement of outcomes such as BMI or cholesterol levels. 

The moral of this story is if you only focus on and reward for LDL cholesterol goals, half of your employees may not only not be helped, but your bottom line may not be all that affected, or even negatively affected with the misguided use of expensive cholesterol-lowering drugs.  For the individual, it is important, as always, to be an informed patient.  Your life just might depend on it.

Best of health to you,

Diane

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