Ten (Okay, Eleven) “Eureka!” Cholesterol Moments
In This Chapter
� Announcing the bad news about saturated fats
� Naming cholesterol as a heart risk
� Tuning up with Mr. Fit
� Pinning the rap on LDLs
� Introducing cholesterol-buster meds
this chapter is a handy guide to a half-century’s worth of advances in the science of protecting your heart by keeping your arteries clean and your body in tip-top shape.
As you read through the list, think about all those people who spent their time sitting at lab benches or adding up statistics to enhance your possibility of living a full, rich life. Clearly, a heartfelt, “Thanks a lot,” is in order.
Finding the “Wow!” factor
The word eureka loosely translates from the Greek as, “Oh, boy, look what I discovered,” a statement most commonly attributed to the ancient Greek mathematician Archimedes.
Sitting in his bath one day, Old Archie suddenly realized that he could calculate the volume of an irregularly shaped solid object, such as him- self, by immersing the object into water and measuring how much liquid it displaced.
Some versions of the Archimedes tale say that right after shouting “Heureka!” (Greek for “Eureka!”), Archimedes leaped out of the tub and ran starkers through the streets of his native Syracuse. Whether his fellow citizens shouted “Heureka!” upon seeing him is lost to history.
1957: The Prudent Diet
The Prudent Diet was the brainchild of the Diet and Coronary Heart Disease Study Project of the Bureau of Nutrition at the New York City Department of Health.
Well before the establishment decided that the risk of heart attack may be lowered by reducing the intake of foods high in saturated fats while empha- sizing unsaturated fats, the New Yorkers (whom I’m proud to say included my uncle, Seymour H. Rinzler, MD) said, “Let’s try it.”
Boy, were they ever right. By the end of the fourth year of the study, the incidence of heart attack among the middle-aged, often-overweight male participants was far below the numbers that researchers had predicted.
As a result, the Prudent Diet became the role model for the American Heart Association’s Step I and Step II eating plans (check ’em out in Chapter 4), and a new approach to eating your way to a healthy heart was born.
1958: Introducing Cholesterol Busters
Cholestyramine (brand name: Questran, Questran Light) was the first cholesterol- lowering drug approved by the U.S. Food and Drug Administration (FDA).
This prescription drug sops up natural digestive juices and bile acids found in your intestines and eliminates them from your body. Because you need bile compounds to digest food, your body responds by converting cholesterol into bile, thus lowering the amount of cholesterol in your blood vessels. (Read the whole story in Chapter 12.)
Cholestyramine is almost 50 years old, and although some of its market has been taken over by the statin drugs (see “1986: Unveiling Statins” later in this chapter), it’s still selling. Two years ago, cholestyramine’s manufacturer appealed to the FDA for permission to sell it as an over-the-counter product rather than a prescription drug. The FDA nixed the idea.
1971: Naming Cholesterol an Official Risk Factor for Heart Attack
Framingham, Massachusetts, is a small industrial town about 20 miles west of Boston. I mean no disrespect to its hardworking inhabitants when I say that you would probably never have heard of Framingham if a team of Boston
University Medical School researchers hadn’t set up shop there shortly after World War II. But they did. And they recruited most of the town’s nearly 30,000 citizens as volunteers in a study of who gets heart disease and why.
Within 20 years, an analysis of hundreds, maybe even thousands, of tests per- formed on the Framingham residents produced statistics showing a relation- ship between high serum (blood) cholesterol and the risk of heart attack. Here are the numbers:
Do those figures look familiar? You bet they do. Just check out the current breakdown for high, medium, and low cholesterol levels in Chapter 3.
More to the point, these numbers led the Framingham researchers and the National Heart Institute to create the first task force on arteriosclerosis, another big step on the road to the general public becoming interested in controlling cholesterol. Yeah, team!
1971: MRFIT Gets Going
The Multiple Risk Factor Intervention Trial (MRFIT) was an eight-year (1974–1982) study in which 250 scientists at 28 medical centers across the United States interviewed 361,662 middle-aged men to get 12,866 volunteers.
The volunteers were thought to be at high risk for heart attack based on risk factors such as age, smoking habits, a high-cholesterol diet, high blood pressure, and obesity.
The guys were divided into two groups: One group was taught to modify their behavior; the other was left to their own devices. At the end of the trial, the big news was that nonsmokers with lower cholesterol and lower blood pressure were less likely to have a heart attack. Today we take that for granted.
1984: Indicting Hypercholesterolemia
In 1984, a 14-member panel of distinguished scientists gathered at the National Heart, Lung, and Blood Institute for a Consensus Development Conference to
analyze the existing studies on cholesterol and heart disease and invite testimony relating to evidence linking the risk factor to the disease.
What they heard was so convincing that they certified hypercholesterolemia — a nine-syllable way to say high cholesterol — as a medical condition worthy of treatment. And just like that, practically overnight, millions of people who
once considered themselves healthy had something to worry about. Ain’t science great?
1985: Recognizing the Risk from LDLs
For years, cholesterol researchers plodded along thinking plain old high choles- terol was the basic risk factor for heart disease. They also wondered why some people with sky-high cholesterol readings never had heart attacks.
Joseph L. Goldstein and Michael S. Brown of the University of Texas Health Center in Dallas changed all that on October 14, 1985, when they won the Nobel Prize for identifying LDLs as the true risk factor in the cholesterol game. Bravo, Goldstein and Brown!
1985–1987: Establishing the National Cholesterol Education Program
The National Cholesterol Education Program (NCEP) was created in 1985, released to an advisory panel in 1986, and announced to the American public in 1987. Based on the Framingham stats (see “1971: Naming Cholesterol an Official Risk Factor for Heart Attack” earlier in this chapter), the NCEP formally designated levels of cholesterol as “high” (>240 mg/dL), “borderline high” (200–239 mg/dL), and “desirable” (<200 mg/dL).
This classification formally declared more than 25 percent of all Americans as being at risk of heart attack from high cholesterol. Wow! Who knew?
1986: Unveiling Statins
Statin is shorthand for a class of drugs that lowers cholesterol at the source by interrupting your liver’s natural production of this fatty substance. The first two statins — pravastatin (Pravachol) and simvastatin (Zocor) — appeared in 1986. The third, lovastatin (Mevacor), came online the following year.
For the full story on statins, check out Chapter 12. For the big problem with statins, run your finger down to “2001: Baycol Bombs.”
1988, 1993, 2001: ATP I, ATP II, ATP III
The National Cholesterol Education Program’s Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults report is one whale of a mouthful, so the whole thing is commonly called ATP (adult treatment panel), which certainly slides more easily off the tongue.
ATP I, published in 1988, focused on prevention and offered tips for warding off heart disease in healthy people with high cholesterol. The report also identified LDLs as a primary target, advising people whose LDLs are higher than “normal” to work with their doctors to reduce their risk for heart disease by lowering LDLs.
ATP II came out in 1993. Once again, the report stressed the importance of getting LDLs down into a healthy range, but ATP II added something new. Moving from prevention for healthy people to the management of existing heart disease, the report urged people who’d already had a heart attack to lower their LDLs, preferably to 100 mg/dL (or less).
ATP III, the current version, appeared in 2001. The advice to lower LDLs is still included, but once again, the National Cholesterol Education Program has come up with something new. The report identifies a new condition called metabolic syndrome (multiple risk factors, such as high blood pressure, obesity, smoking, and high cholesterol) as an important warning of heart disease ahead.
ATP III also offers a version of a medical crystal ball — a risk-factor-based formula that enables you to determine whether you should be on cholesterol- busting drugs (see Chapter 12) and guesstimate your odds of having a heart attack in the next ten years. If you’re brave enough to face the future, you can do the math in Chapter 3.
2001: Baycol Bombs
Baycol, the brand name for the drug cerivastatin, was introduced by Bayer A.G. in 1997 and, as you can see from the date on this entry, taken off the market a scant four years later.
One side effect of statin drugs, a class of cholesterol-lowering drugs, is rhabdomyolysis — the destruction of muscle cells. If enough muscle cells are destroyed, the debris may pile up in your kidneys, triggering kidney failure. Among Baycol users, the incidence of cell damage was ten times greater than it was for people using other statins, and the effect was far more likely to be fatal.
By August 7, 2001, when Bayer took Baycol off the market, at least 31 deaths were linked to the medication in the United States, and the FDA had reports of nine more abroad. As of 2007, the number of deaths attributed to Baycol worldwide has climbed past the 100 mark.
For more details on Baycol and the risks associated with other statins, turn to Chapter 12. The lesson to take away from this short set of paragraphs is simple: Never take any drug without reading the fine print.
2001–2004: Anti-Cholesterol Combo Pills
When it comes to therapeutic drugs, time marches on and so do the innovations. In 2001, Kos Pharmaceuticals introduced Advicor, the first anti-cholesterol com- bination pill. Advicor contains extended-release niacin (believed to raise HDLs, the “good” cholesterol) and the statin drug lovastatin (Lipitor). Three years later, Merck/Schering-Plough released Vytorin, a combo that includes ezetimibe (a drug that reduces the body’s absorption of fats, including cholesterol) plus the statin drug simvastatin (Zocor). And Pfizer introduced Caduet, which contains the anti-hypertension drug amlodipine (Norvasc) plus the statin lovastatin (Lipitor).
The good news about these two-fers is that a person who needs two drugs can get them both in a single pill. The bad news is that the pill provides the risk of two drugs along with the benefits.
Whether the benefits outweigh the risks for a specific patient is a question only that person (and his doctor) can decide. For investors, the answer is crystal clear. In 2006, Advicor scored $116 million in sales; by summer 2007, Vytorin was a $2 billion/year blockbuster; and Caduet sales are predicted to hit $1.1 billion by 2008. Eureka!
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