Monday, December 12, 2011

Recommended 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 Treatment is especially true for people with acute coronary syndromes. How do we know who does and who does not have silent coronary artery disease ? 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. I believe that we are generally not good at making a diagnosis of silent coronary artery disease in any one with out the use of invasive and risky procedures. Also our known risk factors have not been shown to predict who does or does not have coronary heart disease. THe Diad Study published in Diabetes Care 2004 found that 22% of asymptomatic patients with diabetes were found to have silent myocardial ischemia with extensive testing. My thoughts; I believe that most of us would prefer to not have overt cardiovascular disease. We also know that we have limited tools to accurately determine who does and does not have silent coronary artery disease We also have safe effective medications ( statins and others) that can reduce our risk of developing overt cardiovascular disease Why not use these amazing tools and treat to a level of optimal benefit ( LDL < 70mg/dl ) and reduce everyone risk of developing heart disease ? Is age a factor ? 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 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

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Your comments and questions are appreciated. David Calder,MD