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Cholesterol continues to make news, and for good reason. While it has long been known that blood cholesterol level is a key determinant of risk for heart and blood vessel disease, in recent years a number of landmark studies have established that powerful cholesterol-reducing drugs (statims) can dramatically cut this risk and reduce the occurrence of heart attacks and strokes. In the most recent such trial, the largest to date, treatment resulted in 24 percent fewer heart attacks and strokes in men and women who were at high risk for heart disease.

The mounting evidence for the benefits of lowering blood cholesterol, and in particular the LDL ("bad") cholesterol, has led to new guidelines, published last year, for achieving desirable cholesterol and LDL levels, These levels are based on one's overall risk for heart attack or death from heart disease.

People with the highest risk, including those with previous heart or blood vessel disease, are urged to achieve optimal levels of LDL: less than 100. Patients with diabetes, who have a particularly high risk for heart disease (two-thirds die of heart or blood vessel ailments) are also advised to maintain ILDL levels below 100. Desirable ILDIL levels for individuals at lower risk range from 130 to 160.

Despite the remarkable advances that we have seen in cholesterol treatment, car-diovascular diseases remain the leading cause of death in this country. Why?

Most importantly, more than 102 million American adults now have total blood cholesterol readings above desirable levels, and about 41 million of them are at high risk for heart disease, A major culprit for many is diet-too much food that is high in saturated (animal) fat and cholesterol. Too much food, period.

Diet and Exercise
A host of other risk factors for heart and blood vessel disease are aggravated by excessive body weight coupled with inadequate physical activity. Prominent among these is a recently identified cluster of metabolic disturbances that can lead to heart disease as well as diabetes and high blood pressure. Clues to this condition include low blood levels of HDL, a protective, or "good," cholesterol, and increased levels of triglyceride, a blood fat that can increase risk for heart disease. Moreover, a particularly damaging subtype of LDL, termed small dense, or pattern B, LDL, is found in people with this metabolic syndrome. Fortunately, while the syndrome has serious medical conse-quences, these can be effectively curbed by weight loss and exercise. These efforts, together with sound dietary choices, can enable many people to optimize their heart disease risk profile. For others, drug treatment can be beneficial.

Another reason that there has not been greater success in reducing death and disability from heart disease is that many people remain unaware of their risk and thus do not seek adequate treatment before disease strikes. Accurate testing for LDL, HDL and triglyceride levels is now relatively inexpensive and widely available. Together with the emergence of a number of new specialized diagnostic tests that can help to further refine risk assessment, it is possible for anyone to learn whether treatment is advisable to reduce their likelihood of succumbing to heart disease or stroke.

Finally, there are many individuals who are known to be at high risk for heart and blood vessel disease but who have not undergone effective treatment to reduce their risk. A recent survey has found that 50-70 percent of patients hospitalized for a heart attack are not receiving cholesterol-lowering medication at the time of their hospital discharge, despite the fact that nearly all such patients are candidates for treatment. In addition, as many as half of patients who are prescribed cholesterol-lowering drugs are no longer taking them one year later despite the fact that long-term if not lifetime treatment is needed for most such patients. Indeed, a recent report indicates a marked increase in heart attacks and deaths from heart disease within 30 days of discontinuing statin therapy.

Clearly, medical science is continuing to give us new information about cholesterol and new tools to help us use this information to prevent heart and blood vessel disease, For a healthy heart, talk with your doctor about cholesterol, know your numbers and heed what both tell you.

Dr. Krauss is senior scientist in the Life Sciences Division of Lawrence Berkeley National Lab and adjunct professor in the Department of Nutritional Sciences, University of California at Berkeley. He has been a senior advisor to the National Cholesterol Education Program and is the founder and chair of the American Heart Association's Council on Nutrition, Physical Activity and Metabolism.

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