Hypercholesterolemia: Negotiating the Issues

Abstract

Current U.S. guidelines for the treatment of hypercholesterolemia in adults have been widely accepted. Criticisms of these guidelines, however, define the issues now emerging as important in the management of lipid disorders. On the one hand, there are those who say that the guidelines miss those with low cholesterols who also have low HDL levels. On the other hand, the guidelines have been criticized for being too inclusive and have been criticized by health economists who feel that treatment of hypercholesterolemia in younger individuals may not be cost-beneficial. Finally, it has been pointed out that in primary (but not secondary) prevention trials total mortality has been unaffected and higher rates of traumatic death observed. On the other hand, secondary prevention trials and regression studies indicate considerable benefit on both mortality and morbidity in those with established disease. This debate has been misunderstood and has led to undertreatment of hypercholesterolemia, particularly in those with coronary disease. Issues to be settled include the benefit of drug intervention in women, in the elderly, and in young adults without established coronary disease, as well as the role of newer risk factors, including Lp(a), small, dense LDL, and truncal obesity. The cause-effect relationship between cholesterol and coronary disease is accepted. Debate continues about the proper level for cholesterol cutpoints, and the potential value of new lipoprotein risk factors.