It all seemed so simple. If you just lowered your cholesterol you could reduce your risk of a heart attack or stroke.
Drug companies have done their best to keep you focused on medications that bring cholesterol levels down. Turn on TV or open a magazine and you are likely to see an ad featuring Dr. Robert Jarvik, known as the inventor of the artificial heart. He promotes Lipitor to lower cholesterol and he has been wildly successful.
The company brags that its statin-type medication has been prescribed to more than 26 million Americans. Lipitor earned its manufacturer more than $13 billion in 2006.
Lipitor is not alone. Millions of Americans take cholesterol-lowering drugs like Crestor, Mevacor, Pravachol, Vytorin, Zocor and Zetia. But puzzling new data have many patients confused.
Headlines recently announced the results of a study comparing Vytorin, which contains both Zetia (ezetimibe) and Zocor (simvastatin), to Zocor alone. Although Vytorin lowered bad LDL cholesterol 17 percent more than Zocor, the combination pill did not reduce dangerous plaque buildup in neck arteries. The patients on Vytorin may even have had slightly more plaque buildup.
Cleveland Clinic cardiologist Steven Nissen was stunned by the results and called on his colleagues to reconsider routine use of Zetia or Vytorin as first-line treatments. In 2006 18 million prescriptions were written for Vytorin and 14 million for Zetia.
Lowering cholesterol, especially bad LDL cholesterol, is supposed to be the Holy Grail for preventing atherosclerosis and cardiovascular events. But an earlier study of a novel medication called torcetrapib that lowers LDL and raises good HDL cholesterol was abandoned when patients taking the medicine actually had more heart attacks and strokes. The new study of Vytorin suggests that reducing LDL numbers may not be enough.
Even for tried-and-true cholesterol-lowering drugs, the benefit for any given individual may be smaller than people imagine. Lipitor, for example, has been shown in studies to prevent heart attacks.
Newspaper ads capitalize on this, announcing that Lipitor reduces the risk of heart attack by 36 percent. There is an asterisk next to that number, however, and here is the fine print: “That means in a large clinical study, 3 percent of patients taking a sugar pill or placebo had a heart attack compared to 2 percent of patients taking Lipitor.” (See Business Week, Jan. 17, 2008.)
In other words, if you had 100 people taking Lipitor and another 100 people taking an inactive placebo, there would be one less heart attack after several years among the folks on Lipitor. That certainly matters a great deal if you are the one who was spared. But if you are one of the other 99, the cost and risk of side effects may seem high.
No one should stop taking cholesterol-lowering medicine without medical supervision, but cholesterol is not the only thing that matters. Physicians have known for decades that there are over 200 risk factors for heart disease (New England Journal of Medicine, Nov. 14, 2002). Inflammation, stress, hostility, depression and high triglycerides are just a few of the other contributors to heart disease. Focusing on cholesterol alone could be a big mistake.
