Got Cholesterol? Lower It!
People with cardiovascular risk factors benefit greatly from
reduced cholesterol levels, regardless of where they start from
By Will Block
n a famous experiment conducted in 1586, a scientist simultaneously dropped a heavy object and a light object from a tower. He wanted to see whether the heavier object would fall faster and land sooner than the lighter one. Most scholars of that era assumed the heavier object would fall faster, because that was just “common sense.” Besides, Aristotle had declared (19 centuries earlier) that the rate of fall of a body is proportional to its weight—and what Aristotle said was gospel.
Galileo and his legendary falling cannonballs
Fine, except for one thing: Aristotle was wrong. In the experiment, both objects fell at the same rate and therefore landed simultaneously, demonstrating that the acceleration due to gravity applies equally to all objects, regardless of their size or weight. (Even very small or very light objects that are normally slowed down by air resistance are subject to this law of physics—in a vacuum, a feather will fall just as fast as a rock.)
So sixteenth-century common sense was misleading. Not that the common sense of today is any better—we’re still often misled by things that seem “obvious” but that just aren’t true. And, of course, we’re susceptible to appealing legends, such as the one about the falling-objects experiment having been performed by Galileo at the Leaning Tower of Pisa, using two cannonballs. In reality, the man who did this experiment was a Belgian-Dutch physicist named Simon Stevinus, and he did it not in Italy, but in Holland.*
Usually, though, common sense is a pretty good guide about what’s likely to happen under familiar circumstances. If Stevinus had dropped a priceless vase from the top of a tower, and it broke (duh), few people would have suggested that he drop its priceless twin from only halfway up the tower to see if that one would bounce. With falling fragile objects, everyone knows that the starting point doesn’t much matter.
Even Lower Cholesterol = Even Better Health
With falling cholesterol levels, however, common sense suggests that the starting point would matter, right? Surely an unhealthy you with high cholesterol levels would have more to gain by reducing your levels than a healthy you whose levels were already gratifyingly low. In fact, you might well think that if your cholesterol levels were so low that you were already at low risk for a heart attack or stroke, there would be little point in trying to lower them further. After all, how healthy can you get?
The answer is: healthier than you think! With cholesterol levels, it seems, we’re dealing with another situation, like falling vases, in which your starting point really doesn’t much matter. But whereas dropping a vase is always a bad idea, dropping your cholesterol levels—regardless of your starting point—will almost certainly make you healthier, especially if you already have significant cardiovascular risk factors other than high cholesterol.
British Launch Massive Study
Several hundred British researchers and physicians who constitute the MRC/BHF Heart Protection Study Collaborative Group conducted a study of this issue under the auspices of the United Kingdom’s Medical Research Council and the British Heart Foundation. Between 1994 and 2001, medical collaborators from various universities and 69 hospitals in the UK evaluated the effects of cholesterol-lowering therapy on cardiovascular risk factors in 20,536 men and women aged 40 to 80 years.
The objective was to see how much the subjects would benefit from cholesterol-lowering therapy over a 5-year period, even if their levels were low to begin with. The subjects’ initial, nonfasting, total cholesterol levels ranged from a low of 135 mg/dL (milligrams per deciliter) to the high range of 240 mg/dL and above; the average was 228, which is in the “borderline high” range. The subjects’ average LDL (“bad cholesterol”) level was 131 mg/dL, which is borderline high for that category, and their average HDL (“good cholesterol”) level was 41 mg/dL, which is in the desirable range of 35 and above.
Read This! — For Your Heart’s Sake
The British study discussed in the accompanying article is so definitive, and the results so dramatic and important for our health and longevity, that it’s worth quoting the authors at some length. Following are a few excerpts from the Discussion section of their paper (bear in mind that cholesterol reduction with policosanol might have produced similar results and conclusions).
“The results of the Heart Protection Study demonstrate that lowering LDL-cholesterol with a statin produces a substantial reduction in the incidence of major vascular events among a much wider range of high-risk individuals than had previously been shown to benefit from such treatment. In particular, it demonstrates substantial benefit not only in those already known to have coronary disease, but also in those without diagnosed coronary disease who have cerebrovascular disease, or peripheral arterial disease, or diabetes (for each of which there had previously been little direct evidence of benefit), irrespective of the blood lipid concentrations when treatment is initiated. [Italics ours.] The large numbers of participants studied in a wide range of different circumstances (e.g., prior disease, age, sex, presenting lipid concentrations, other management) allow these results to be generalized widely. . . .
“The present study deliberately included large numbers of older individuals and of women, and it demonstrates substantial benefit in old age as well as middle age, and in women as well as men. . . . the benefits of statin therapy appeared to be largely independent of, and hence additional to, those of all the other treatments being used by the participants, including antihypertensive therapy and various other types of cardioprotective drugs . . . .
“The Adult Treatment Panel (ATP III) of the U.S. National Cholesterol Education Program has recently recommended that the LDL-cholesterol concentrations of people considered to be at high risk because of pre-existing coronary disease (or at equivalent coronary risk for other reasons) be reduced to below 100 mg/dL. . . . [Our findings] indicate that current guidelines may inadvertently lead to substantial under-treatment of high-risk patients who present with LDL-cholesterol concentrations below, or close to, particular targets (such as 100 mg/dL in the ATP III guidelines) . . . .
“Moreover, these findings suggest that, other things being equal, a downward shift of the whole LDL-cholesterol distribution typically found in Western populations would lead to reductions in the incidence of vascular disease (and there was no evidence in the present trial that such a change would be associated with any material adverse effects). . . .
“The Heart Protection Study has . . . shown unequivocally that statin therapy prevents not just coronary events and coronary revascularizations, but also ischemic strokes and peripheral revascularizations. Hence, decisions about whether to initiate therapy should perhaps now be guided by the estimated risk of suffering any such major vascular event, and not just a coronary event. . . . Indeed, the results suggest that it might be worth considering statin therapy in people at somewhat lower risk of these major vascular events than those in the present study.”
Subjects at High Risk for Heart Trouble
Regardless of their cholesterol levels, however, none of the subjects were healthy. All of them had at least one of the following conditions: (1) coronary heart disease, (2) other occlusive arterial disease, i.e., a disease caused by obstruction of arteries, such as cerebral ischemia (impaired cerebral blood flow), or (3) diabetes, which is a major risk factor for heart disease. In order to be admitted to the trial, in fact, the subjects had to be deemed by their doctors to be at a substantial 5-year risk of death from coronary heart disease because of a past history of any of the following conditions:
- Coronary disease, such as a heart attack, stable or unstable angina pectoris, coronary angioplasty (surgical repair of a coronary artery, usually done with a balloon catheter), or a coronary artery bypass graft.
- Occlusive disease of noncoronary arteries—e.g., a nondisabling stroke thought to be caused by arterial obstruction rather than hemorrhage; transient episodes of impaired cerebral blood flow; narrowing of arteries in the legs, causing intermittent claudication (painful walking); or a revascularization. (Revascularization is any surgical procedure that provides a new or augmented blood supply to a body part or organ. Clearly such procedures are not undertaken unless the patient is in bad shape, which is why revascularization is considered to be a sign of poor cardiovascular health.)
- Diabetes, either type 1 (insulin-dependent) or type 2 (non-insulin-dependent).
- Treated hypertension (provided the subject was also male and aged at least 65 years, in order to be at similar risk to the other three disease categories).
The subjects chosen had to be largely free of other diseases whose effects might interfere with the interpretation of the results. Also, those who were deemed unlikely to comply with the requirements of the study’s projected 5-year duration were screened out. By this laborious process of evaluation, the researchers winnowed the initial field of 63,603 candidates down to 20,536 (75% men and 25% women)—still a huge number by any standard of clinical testing.
Statin Drug Reduced Cholesterol Levels
Falling cholesterol (the red atom is oxygen)
So what did the researchers do with these subjects? On a randomized, double-blind basis, they gave half of them (daily) a placebo and the other half 40 mg of the cholesterol-lowering drug simvastatin (Zocor); then they monitored all of them at 6-month intervals for 5 years. At each session, they took blood samples to monitor the subjects’ liver function (a potential safety concern when taking statin drugs, although that turned out not to be a factor in this study), and they recorded information on any suspected heart attack, stroke, vascular procedure, cancer, or other serious medical problem.
To assess the treatment’s effects on the subjects’ blood lipid profiles, the researchers tested nonfasting blood samples collected from a selected segment of about 5% of the total study population throughout most of the study period, and from all the participants during a 7-month period near the end of the study. Over the course of the study, the average reductions in total cholesterol and LDL-cholesterol levels (compared with placebo) were 46 mg/dL and 39 mg/dL, respectively.
Policosanol Rivals Statins in Efficacy
Here it should be mentioned that the costly statin drugs, for all their effectiveness in reducing cholesterol levels, are not the only game in town. A very safe and effective (and far more economical) natural alternative is the sugar-cane extract policosanol, which has been found in numerous studies to rival—and sometimes exceed—the statins in its ability to reduce total cholesterol and LDL-cholesterol levels (as well as triglycerides) while substantially increasing HDL-cholesterol levels.* (Policosanol is not a sugar and has no effect on blood sugar levels.)
Thus, it is not unreasonable to speculate that the results of the British study might have been similar if policosanol had been used instead of simvastatin. Now let’s return to that study.
When the mountains of data were analyzed, the results showed—with extremely high statistical significance—that, compared with placebo, simvastatin reduced the coronary death rate by 18%, the incidence rate of first heart attack by 38%, the incidence rate of first stroke by 25%, and the incidence rate of first revascularization by 24%. The overall reduction in “event rate” from all vascular causes was 24% (i.e., a reduction by about one-fourth).
Actually, that figure is low because, during the course of the study, about one-sixth of the simvastatin group stopped taking the drug, and about one-sixth of the placebo group started to take a statin drug independently of the study. When these anomalies were properly accounted for, the authors concluded that a perfect compliance record would have yielded an approximately 50% greater reduction in the average LDL-cholesterol level and a reduction in the event rate from all vascular causes by about one-third rather than one-fourth.
Remarkably, these health benefits were found to be similar in all the defined subcategories of participants in the study: they applied similarly to men and women, to those below 70 and those above 70, and to those with coronary heart disease and those without it (the latter, however, did have at least one of the other “required” diseases mentioned above). Most notably, the benefits applied as much to those whose cholesterol levels were initially low as they did to those whose cholesterol levels were initially high! In other words, cholesterol reduction was beneficial for everyone, regardless of their sex, age, disease status, or initial cholesterol levels. The authors described the evidence as “unequivocal.”
Furthermore, the benefits were independent of simultaneous treatment for hypertension (high blood pressure) and of the use of aspirin, beta-blockers, or ACE (angiotensin-converting enzyme) inhibitors. Hence, the benefits of simvastatin augmented the benefits of these other heart-protective therapies.
No Effect on Various Other Diseases
A “major surprise” is how one expert has described the results of a just-published study. Using twice the normal dosage of atorvastatin (Lipitor) and comparing it with the normal dosage of pravastatin (Pravachol) in a large-scale international trial on patients who had recently been hospitalized for an acute coronary syndrome, researchers found a much larger than expected reduction in LDL-cholesterol levels and an additional 16% reduction in the risk for death or major cardiovascular event.
These results suggest that much more aggressive cholesterol-lowering therapy is advisable, for many more people, than had ever been thought. We will discuss this exciting new research in next month’s issue.
- Cannon CP, Braunwald E, McCabe CH, Rader DJ, Rouleau JL, Belder R, Joyal SV, Hill KA, Pfeffer MA, Skene AM, for the Pravastatin or Atorvastatin Evaluation and Infection Therapy–Thrombolysis in Myocardial Infarction 22 Investigators. Comparison of intensive and moderate lipid lowering with statins after acute coronary syndromes. New Engl J Med 2004 Apr 8;350 (online ed.).
Unfortunately, simvastatin had no effect on the incidence rates for two conditions for which there was some reason to believe that cholesterol reduction might be beneficial, namely, neuropsychiatric disorders (such as dementia), and fractures related to osteoporosis. Conversely (and fortunately), simvastatin also had no effect on the incidence rates for a disease for which there was some slight reason to believe that major cholesterol reduction might be detrimental, namely, cancer (breast cancer in particular): there was no effect on cancer in general, or on any specific cancer. Finally, simvastatin had no apparent effect on blood pressure or body weight, and it did not affect hospitalization rates related to any other particular reason.
The authors emphasized that the huge number of subjects involved in this study endows the results with great statistical validity, making them far more reliable than those of many other studies in which relatively small numbers of subjects were involved. Numbers count!
Even If Your Cholesterol Levels Are Low,
They’re Still Too High
What this study tells us is that all people with significant cardiovascular risk factors would benefit similarly from lowering their cholesterol levels, regardless of where they started from (even if that seems to violate common sense). Indeed, as more and more physicians are coming to believe—and advocate—doing this might very well benefit all adults, whether they’re currently known to be at cardiovascular risk or not.
For the sake of your heart health, you should take this idea, well, to heart. And if policosanol rather than a statin drug is your choice for lowering your cholesterol levels, you can take all the money you’ll save to the bank.
- Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet 2002 Jul 6;
Will Block is the publisher and editorial director of Life Enhancement magazine.