Questions on Cholesterol Lowering & Levels

Dear Dr. Spence,
I am concerned with recent news regarding the use of the cholesterol lowering medication, vytorin. Am I being placed at unnecessary risk by being on it?
Signed,
HDL

Dear HDL,
The concerns behind the "mass hysteria" about this drug are all based on the results of the ENHANCE trial. This study investigated plaque formation in the carotid artery and found that there was no significant difference between the uses of zocor versus vytorin (vytorin is the equivalent of zocor and zetia in combination). Given the fact that zocor is generic and has proven benefit, it has been argued that adding the zetia component is useless. Unfortunately, this study was not designed to assess whether or not either medication was superior in preventing heart attacks or strokes. As of yet, it is unclear if the zetia component makes a difference in preventing serious outcomes. Should a patient be taken off vytorin? This is a complex question. We do know that lower LDL cholesterol (bad cholesterol) remains the primary focus of lipid lowering strategies. Vytorin seems to be the best at doing this, so one would argue that it is the best medication to be on, period. Again, studies comparing vytorin and zocor are underway, therefore we cannot say vytorin is inherently better at preventing strokes and heart attacks. I always look for the cheapest alternative without compromising health and zocor is certainly a great first line choice in lipid lowering. If a patient is at goal on vytorin, it may be wise to keep them on the medication rather than rock the boat. Final answers to this question will be available in 2010 (roughly) once the head-to-head trial has been completed.

Dear Dr. Spence,
What should my cholesterol level be? I am 45 years old without any medical problems.
Signed, Curious George

Dear George,
From the standpoint of LDL cholesterol (bad cholesterol), we know that for every 30 point increase there is an increased risk of heart disease by 30%. This underscores the importance of lipid lowering in combating death from heart attack. Generally, a physician will evaluate overall risk and determine a cholesterol goal. In your case, it is recommended that the LDL be less than 160. On the other hand, throw in risks like smoking and hypertension, and then the goal may change to 130 or less. Patients with known diabetes are encouraged to keep their LDL levels below 100 and patients with known coronary artery disease are urged to push to below 70. The other parameters (i.e. triglycerides and HDL or good cholesterol) are also important but take a back seat compared to LDL. HDL should be as high as possible, preferably greater than 40-45 depending on sex. Triglycerides should be generally less than 150.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.