4-11 ADHERENCE TO NATIONAL CHOLESTEROL EDUCATION PROGRAM TREATMENT GOALS IN POSTMENOPAUSAL WOMEN WITH HEART DISEASE
Coronary heart disease (CHD) is the most frequent cause of death among women. The prognosis for women after myocardial infarction is comparable to, or worse than, for men.
In 1993 the NCEP adult treatment panel guidelines recommended that, for persons with symptomatic CHD, LDL-cholesterol levels should be less than 100 mg/dL (2.6 mmol/L).
This study determined the proportion of women with established CHD who reach the goal.
Conclusion: Fewer than 10% reached the goal.

STUDY
1. Multicenter cross-sectional investigation measured lipid levels in over 2500 postmenopausal women (mean age 67) with established CHD.

RESULTS

1. About half were taking lipid-lowering drugs. (Very few were taking hormone replacement therapy.)
2. Only 9% reached an LDL-c level of less than 100 mg/DL— 37% reached the goal of less than 130 mg/dL.

DISCUSSION

1. Individuals taking lipid-lowering medications probably were not having their dose titrated to achieve the goal of LDL-c < 100 or < 130.
2. The effect of being elderly and a woman might independently contribute to being undertreated.
3. In the Scandinavian Simvastatin Survival Study (a secondary prevention trial), participants receiving the drug lowered their LDL-c from a mean of 188 to 117 mg/dL. Women, as well as men achieved significant reductions in coronary events (about 33% in both women and men).
4. If diet and full doses of the newer reductase inhibitors were used, a 60% LDL-c reduction might be expected. This would achieve reduction in LDL-c level from 152 mg/dL to 61 mg/dL.
5. If all participants had taken hormone replacement therapy in addition to lipid-lowering drugs, there might have been an additional decrease in the LDL-c level.

CONCLUSION
The great majority of women in this study had LDL-c levels that significantly exceeded the treatment goals set by the guidelines.
JAMA April 23/30 1997; 277: 1281-86 Original investigation from the Heart and Estrogen/progestin Replacement Study, first author from Univ. Of Iowa, Iowa City.

Comment:
I believe the first interventions in postmenopausal women should be diet and hormone replacement. (For prevention as well as treatment.)
A statin drug could be added if, for the individual, a reasonable assessment of the benefit/harm-cost ratio would indicate use. (Fortunately statin drugs are safe.) The cut point of 100 mg/dL is arbitrary. As noted above in the simvastatin study one does not have to reach this goal to benefit.
The goal of lipid control is not to lead to anatomical regression of lipid plaques (this may take years), but to stabilize the surface of the plaque, prevent rupture, and thrombosis. Stabilization is enhanced by lipid control and can take place within a much shorter time (1 to 2 years). Thus, age per se should not deter attempts at lipid control particularly in patients with established CHD.
In addition to lipid-lowering treatment, other established preventive drug treatments are underused in both men and women with CHD (aspirin, beta-blockers, ACE inhibitors). RTJ

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