Lipid Management to Reduce Cardiovascular Risk: A New Strategy Is Required

Abstract

“It is not good to settle into a set of opinions. At first putting forth great effort to be sure that you have grasped the basics, then practicing so that they may come to fruition is something that will never stop for your whole lifetime. Do not rely on following the degree of understanding that you have discovered, but simply think…This is not enough.” — Hagakure, Yamamoto Tsunetomo, September 10, 1716 (a Samurai)1 For the past 22 years, substantial national efforts have been directed toward reducing the average blood low-density lipoprotein cholesterol (LDL-C) level of the American population. This initiative was initially prompted by the successful results of the Lipid Research Clinic–Coronary Primary Prevention Trial (LRC-CPPT), which first proved that reducing LDL-C resulted in a statistically significant reduction in cardiovascular events.2 The intent of these efforts has been to reduce the human suffering and economic cost of cardiovascular disease. In the subsequent 2 decades, a plethora of monotherapy cholesterol-lowering drug trials has consistently reported a statistically significant 25% relative risk reduction for cardiovascular events. These findings form the basis for the current Adult Treatment Panel (ATP) III guidelines and the recent call to adjust the LDL-C goal even lower.3 Response by Grundy p 568 Although this level of success in the fight against heart disease is laudable, a great danger for our patients’ future health lies in the assumption that cholesterol reduction alone will stem the tide of coronary heart disease (CHD). It is wise and prudent to remember the words of Yamamoto Tsunetomo that “this is not enough.” The purpose of this article is to challenge healthcare workers to consider the possibility that the cholesterol-lowering program has in large part failed to stem the epidemic of CHD and that the well-meaning focus on LDL-C reduction has deflected …