In reading this thread, I'd like to make some clarifications on diagnosis and treatment of dyslipidemias.
Treating the risk of heart disease is very important. CDC's last mortality statistics for 2003 show that heart disease still outpaced cancer for mortality. I heard on the radio that cancer is now the leading cause of mortality, but I didn't find any sources for this statistic. The rates of both heart and cancer mortality have been declining steadily.
ONe talks about the miniscule reduction in survival. Statistically, this "small" reduction may mean a much more dramatic reduction in MORTALITY. I would need to see the study results, but all cause mortality does not include a breakdown to the reduction in heart disease mortality, which I'd like to see. Moreover, if heart disease is only a fraction of total mortality, and the reduction is still strikingly large, it further accentuates the benefit of treatment of LDL with statins.
I take exception to the implication that doctors treat with statins because they don't wanna get sued. That would be a gross oversimplification of the process of assessment of a patient, educating the patient on the risk, negotiating a plan of treatment, and following up.
In one thread, it mentioned that total cholesterol stayed the same while the HDL went up and LDL stayed the same -- this is possible, since the fractionation of the lipoproteins only routinely measures LDL and HDLs, not VLDLs (very low density lipoproteins) and IDLs (intermediate density lipoproteins). THat also makes total cholesterol a poor indicator for stratification of coronary heart disease (CHD) risk.
Another comment was that why use HMGCoA reductase inhibitors (aka "statins") in the treatment of LDL cholesterol. What is compelling about the use of statins is that they significantly lower the risk of heart disease in all patients, that is to say, those who already have had MI, those who have no other risk factors for heart disease, those who have risk factors but no CHD yet -- virtually anyone. The question is: Who needs a reduction in risk? The decision lies with the doctor / patient and their comfort with risk.
4 counterpoints to statin therapy:
1. There is no reduction of CHD risk to zero.
2. One may always try lifestyle modification for low-to-moderate risk of CHD.
3. If the risk of CHD is very low (e.g. <0.5% cumulative 10 year), the risk and expense of treatment may outweigh the benefit from treatment.
4. Everyone is gonna die anyway, so depending on your life circumstance, it may not be worth it to treat the risk of CHD. E.g. an 80 year old in an assisted living home who suffers from painful multiple chronic medical conditions (stroke, arthritis, diabetes, hypertension). You must weigh quality of life and risk of all-cause mortality in assessing the benefit of decreased mortality and morbidity of CHD.
According to NCEP ATP III (National Cholesterol Education Program Adult Treatment Panel) which is the basic framework for the risk assessment and primary prevention of heart disease:
The assessment of heart disease requires a thorough history including age, gender, past history of CHD, family history of CHD, smoking, other medical problems including diabetes and high blood pressure. Also, cholesterol is needed for assessment of heart disease. Framingham risk scores, which are derived from total cholesterol, HDL, smoking, blood pressure, age, gender to determine the population-based cumulative 10 year risk for CHD events (notice I didn't say mortality)
In addition, the treatment goals start with LDL. HDL, triglycerides, and metabolic syndrome are 2ndary targets for treatment.
