Monday, December 12, 2011

Goals for LDL cholesterol. Is there a level of optimal benefit ?


What are  the recommended goals for LDL cholesterol for people with diabetes?

American Diabetes Association 2010

For individuals "without  overt "cardiovascular disease  the primary goal is an LDL < 100 mg/dl (2.6 mm/l)
For individuals "with overt" cardiovascular disease, a lower goal of < 70 mg/dl (1.8mm/l)

My thoughts on these targets starts with questions .

Is an LDL result of < 70 mg/dl the level of optimal benefit ?
     Recent clinical trials have demonstrated that reducing LDL  levels minimally above 100mg/dl  by about 30 to 40 
    %  to effective in reducing cardiovascular events. 
    This is especially true for people with acute coronary syndromes.

How do we know who does and who does not have silent coronary artery disease ?

                               We don't know because it is silent !

      Coronary calcium deposits can be detected with special CT scans and  intra-coronary artery ultrasound procedures  can detect hidden vascular disease. However there is  increased cost and risk  that prevent there use in our routine screening test. 
     I did have the a coronary calcium CT assessment  done and was happy to know that I had negligible coronary artery calcium. However I also realize that the test did not completely rule out silent coronary disease. The test did detect  asymptomatic significant coronary calcium in a friend  who subsequently had coronary bypass surgery.

    Also our known risk factors have not been shown to predict who does or does not have coronary heart disease. 
 reported that 22% 
   The Diad Study published in Diabetes Care August 8 2004 ;1954-1961 reported that 22 % of asymptomatic
    patients with diabetes were found to have silent myocardial ischemia with extensive testing. 

My thoughts;
      We know who is at risk .
      We know what the risk factors are for heart disease.
      We know that we can correct the risk factors and reduce the risk of developing heart disease.
      We know that we have safe effective medications  for reducing risk.
      I believe that most of us would prefer to not have overt cardiovascular disease. 
      Why not use these amazing tools and treat to a level of optimal benefit ( LDL < 70mg/dl ) and

      reduce everyones risk of developing heart disease? 

There are some things to consider . 
        Is age or  type of diabetes a factor  in making the decision ?

           Most of the risk factor management  for people with diabetes is about " reducing long term risk ".  
           You may have noticed that long term becomes a little shorter as we approach Geezerhood .

         (check out  Diabetes Office visit chapter 8 page 53 ,The definition of long term from an old geezers 
              perspective, for a lighter look at this problem. Diabetes Office visit , is a lighter look at simplifying the complex
               issues of diabetes care. )
         How does  HDL and Triglyceride test results effect my  treatment decision ?  
         Would checking  my  Apo- b level help in making my treatment decision ?
       My LDL has improved but is still well above the recommended goals. Should I stay on the 
        medication ?
I will continue this discussion on lipids and diabetes . Your questions and opinions are welcome . 
                     Have fun            Dr. Calder 

1 comment:

  1. Teenage girls need at least 1,500 to 2,000 calories per day, depending on their fitness regimens and heights. Starvation diets that limit calories to significantly lower than the FDA-recommended amount can cause the body to store fat. When you begin eating normally, the weight will usually come back, and sometimes even increase. Thanks a lot.


Your comments and questions are appreciated. David Calder,MD