Reader's CommentPublished in the American Journal of Cardiology
National Cholesterol Education Program Adult Treatment Panel-III Guidelines and the Abolition of Symptomatic Coronary Artery Disease
Regarding the reassessment of the National Cholesterol Education Program Adult Treatment Program-III (NCEP ATP-III) cholesterol guidelines referred to in the article by Ansell and Waters1 concerning "optimal" low-density lipoprotein (LDL) cholesterol levels, the trend continues toward a more coronary artery disease-free recommendation. To me, the current NCEP ATP-III guidelines are so confusing that, even as a board certified cardiologist, I cannot manage them. In addition, these criteria missed 75% of myocardial infarctions occurring before the age of 55 years, as reported by Kwame Osei Akosah, MD, at the 2002 Eighth World Congress on Heart Failure. At some levels of blood cholesterol coronary artery disease does not occur. Virtually all pre-technologic societies have a total cholesterol of 90 to 130 mg/dl with the associated benefit of no known coronary disease (and a vastly decreased incidence of diverticulitis/arthritis /cancer of the colon/prostate/uterus/breast, and so on).
Thirty-five percent of coronary events occur with a total cholesterol between 150 to 200 mg/dl.2 In the Framingham study, Castelli3 has found that coronary artery disease essentially ceases to exist with a serum total cholesterol <150 mg/dl. It has become increasingly clear that for those with documented atherosclerotic vascular disease (post myocardial infarction and/or coronary artery disease documented by angiography or coronary ultrasound) or diabetes mellitus that the ideal goal would be total cholesterol of 130 mg/dl. The roles of other risk factors and/or risk predictors, such as high density lipoprotein, interleukin-6, cardiac highly specific C-reactive protein, lipoprotein(a), LDL sub fractions for pattern A or B, oxidized LDL and its antibody, homocysteine, matrix metaloproteinases, adhesion molecules, and other cytokines, are also being elucidated.
My own inner-city practice experience, which began 30 years ago, is identical to that of Ornish4 and Esselstyn.5 Virtually none of my patients have developed any cardiac ischemic event if their total cholesterol is kept <150 mg/dl. If patients do have coronary disease, none have had a repeat cardiac ischemic event of any variety in my series of 20 consecutive and unselected patients. These patients are now 20 plus years after their cardiac procedure, and their total cholesterol is kept under 130 mg/dl (usually with an LDL of 75 mg/dl).
This absence of symptomatic coronary artery disease is accomplished using a very high fiber (much, much higher than is currently recommended [75 to 100g/day of whole, unprocessed, and ideally organic]) foods with fish twice a week and anything once in a while, along with statins and/or niacin and/or fibrates and/or thiazolidinediones and/or biguanides when necessary (commonly). Such an approach can (and does in my, Ornish's, and Esselstyn's cases) achieve the abolition of symptomatic myocardial ischemia when a cholesterol level <150 mg/dl is achieved for healthy patients and <130 mg/dl for those who have documented coronary disease and/or diabetes mellitus. We should not treat for a decrease in cholesterol-induced atherosclerotic disease, we should be about its absolute prevention, and such is within our grips.
It is with these facts and opinions6,7 that I make the following recommendation. I propose that the NCEP ATP-III guidelines be scrapped because of their complexity, unlearnability, and ineffectiveness because the total prevention of symptomatic coronary artery disease and real preventive cardiology are physical realities as outlined previously when utilizing much simpler markers (serum total cholesterol either <150mg/dl for healthy patients or <130 mg/dl for those with myocardial ischemia and/or diabetes).
H. Robert Silverstein, MD
14 October 2002
- Ansell BJ, Waters DD. Reassessment of National Cholesterol Education Program Adult Treatment Panel-III guidelines: one year later. Am J Cardiol 2002;90:524 -525.
- Castelli WP. The new pathophysiology of coronary artery disease. Am J Cardiol 1998;82:60T-65T.
- Roberts W. Getting more people on statins. Am J Cardiol 2002;90:683-685.
- Ornish D, Scherwitz LW, Billings JH, Gould KL, Merritt TA, Sparler S, Armstrong WT, Ports TA, Kirkeeido RL, Hogeboom C, Brand RJ. Intensive lifestyle changes for reversal of coronary heart disease. JAMA 1998;280:2001-2007.
- Esselstyn CB. Updating a 12-year experience with arrest and reversal therapy for coronary heart disease (an overdue requiem for palliative cardiology). Am J Cardiol 1999;84:339 -341.
- Silverstein HR. Preventing heart disease. Lancet 1990;335:227.
- Silverstein HR. Coronary artery disease virtually preventable. Med World News 1994;34:17.