Gaps in anti-cholesterol therapy cited

Physicians do not seem aggressive enough in treating cholesterol problems.

The significant benefits of the anti-cholesterol class of drugs called statins in the prevention of coronary heart disease (CHD), heart attacks and strokes are well-established. Yet, medical experts lament that only a small number of eligible patients are currently being treated to the low-density lipoprotein cholesterol (LDL-C) goal recommended by the National Cholesterol Education Program (NCEP) in the United States. LDL-C is the bad type of cholesterol.

The American Heart Association, the American College of Cardiology and the NCEP have all developed guidelines for improving care of patients with elevated cholesterol. However, physician adherence to these guidelines remains sub-optimal. A large "treatment gap" continues to exist between therapies recommended by national guidelines for patients with CHD and the care that they actually receive.

This treatment gap has been extensively documented in both Europe and the United States. In addition, community-based retrospective studies of patients with CHD report that 43 to 67 percent have cholesterol tests, only 27 to 39 percent of patients are given anti-cholesterol therapy, and only nine to 11 percent of the total CHD population is treated to an ideal LDL-C level of less than 100 mg/dL. Only 23 to 31 percent of the total population is treated to an LDL-C level of 130 mg/dL.

There is clearly a need for appropriate dose titration and perhaps higher starting dosages. Although patients are treated, they may not be treated according to recommended goals. Failure to achieve treatment goal may be caused by inappropriate lipid medication use, low initial dosage, low-potency lipid medication use, patient non-compliance, or inadequate dose titration. The lower goal for patients with CHD or multiple CHD risk factors (RFs) also illustrate the difficulty of achieving LDL-C goal.

Several clinical trials have documented the efficacy of simvastatin in improving the lipid profile using forced-dose titration (this occurs when a patient is started on an initial dose of medicine and subsequently receives increasing doses of the medication as per study protocol), but studies of treatment with simvastatin in usual care settings are needed to guide selection of an appropriate starting dose and subsequent titration. A higher starting dose may be helpful for patients who require large LDL-C decreases to achieve the LDL-C goal.

In developing and underdeveloped countries, cost of medicine is always a problem leading to poor compliance. Statin, one of the relatively more expensive medicines in cardiovascular medicine, may not be taken at the right dose and long enough to give significant benefits to the patient. The introduction of an affordable simvastatin by Therapharma may help alleviate this problem in Filipino patients who may need statin therapy.

CHD and treatment for hypercholesterolemia

The association between hypercholesterolemia or dyslipidemia and CHD is well-documented. It has been suggested that statin therapy may have a wider application in the treatment of dyslipidemia in addition to reducing LDL-C levels.

New findings from the 20,000-patient Heart Protection Study (HPS) conducted in the United Kingdom show that simvastatin also cuts the risks of heart attacks and strokes in the high-risk population, which includes patients with diabetes, narrowing of arteries in their legs, and a history of heart attack or stroke.

Even those high-risk patients considered to have normal or low cholesterol levels benefited from the use of simvastatin. This supports the use of statin for anybody at increased risk of either heart attacks or strokes. Although the exact mechanisms are not that well-understood, there is strong reason to believe that statins may confer clinical benefits in patients which may not be solely attributable to cholesterol-lowering.

Lower LDL-C levels though are associated with more benefits. This should motivate physicians to be more aggressive in bringing down the LDL-C of their patients to the target or desirable level.

Another type of patients who are classified as high-risk are those with combined hyperlipidemia, defined as elevations in both total cholesterol or LDL-C levels and triglyceride levels. They account for 10 to 20 percent of those with elevated cholesterol levels.

Medical experts estimate that combined hyperlipidemia occurs in up to seven percent of the entire population and up to 16 percent of diabetic patients. Patients with combined hyperlipidemia face a greater risk of coronary heart disease compared with patients with elevated LDL-C levels alone and may especially benefit from statin therapy.

Statins have been called as the new "super aspirins" and their sustained use by high-risk patients may not only prevent heart attacks and strokes, but may also make unnecessary what were previously strong indications for doing coronary bypass surgeries. Both the physician and the patient can help fill in the treatment gap and improve the patient‘s prognosis and outlook for a healthier and longer life despite the risk factors.