Cholesterol and coronary artery disease. What do clinicians do now?

Coronary atherosclerosis and its clinical sequelae are problems of enormous magnitude. Because the first clinical sign of coronary artery disease may be sudden death, investigators have searched for signs or symptoms of coronary atherosclerosis before it becomes symptomatic. Among these signs or risk factors are elevated plasma levels of total cholesterol or low-density lipoprotein cholesterol, or a reduced level of high-density lipoprotein cholesterol. Recent studies complement older epidemiologic, genetic, metabolic, morphologic, and animal data by demonstrating directly in humans the value of cholesterol change. These studies have shown that a reduction in total plasma cholesterol or in low-density lipoprotein cholesterol and/or an elevation in high-density lipoprotein cholesterol results in decreased development of angina, positive exercise test results, and referral for coronary artery bypass surgery, as well as reductions in more severe cardiovascular end points such as heart attack, heart death, and atherosclerotic plaque progression. In the Lipid Research Clinics Coronary Primary Prevention Trial with hypercholesterolemic men, every 1 percent reduction in plasma cholesterol levels was associated with a 2 percent reduction in coronary risk. Today, the issue is no longer whether a reduction in cholesterol levels is beneficial. The questions now are much more practical: whom to treat, when to treat, and how to treat. The potential public health value of reducing cholesterol levels is enormous. Such a reduction should be espoused by all health care professionals, because it promises a better and longer life for persons at risk for coronary artery disease.