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More Evidence that Risk Factor Modification Works For Coronary Artery Disease

LDL cholesterol and blood pressure especially important


Updated November 13, 2011

If you have coronary artery disease (CAD), you are used to hearing (and no doubt are tired of hearing) that it is important to take aggressive steps at modifying your cardiac risk factors -- cholesterol, blood pressure, diet, weight, exercise and smoking cessation. But, while risk factor modification makes sense, proving that aggressive control of risk factors can actually make a significant difference has been surprisingly difficult. But a study from the Cleveland Clinic ought to make you sit up and take notice.

This study suggests that the progression of atherosclerosis can not only be slowed, but can often be reversed, by the aggressive management of two specific risk factors for atherosclerosis -- LDL cholesterol and hypertension.

Clinicians from the Cleveland Clinic examined over 3,000 patients with proven CAD who had been enrolled in one of several clinical trials. These patients were divided into one of four categories based on whether or not their LDL cholesterol levels were 70 mg/dl or lower, and whether or not their systolic blood pressures were 120 mm Hg or lower. All patients had their "plaque burden" (the amount of atherosclerosis in their arteries) monitored by IVUS (intravascular ultrasound).

The investigators found that patients with CAD who had both low LDL cholesterol levels and low systolic blood pressures (generally because they were taking both statins and blood pressure medication) had the slowest progression of atherosclerosis, and in many cases had actual regression of their atherosclerotic plaques. Patients who had either higher cholesterol levels or higher blood pressures had less favorable results, and generally displayed continued progression of atherosclerosis.

What This Study Means To You If You Already Have CAD

This study, while not conclusive, suggests several important things.

First, it suggests that aggressive risk factor modification, in general, may do more than just slow atherosclerosis -- it may actually cause the disease to improve.

Second, the study adds yet more evidence to the hypothesis that achieving very low LDL cholesterol levels -- which almost always requires the use of statins -- ought to be an important and definite goal in people who have known CAD.

Third, it suggests that, in patients with proven CAD, the target systolic blood pressure ought to be 120 mm Hg or lower. Currently, patients with systolic blood pressures between 120 to 140 mm Hg are considered to have only "pre-hypertension," and medical therapy is not usually recommended. At least for patients who already have CAD, it appears that "pre-hypertension" ought to be reclassified as actual hypertension, and that anti-hypertensive therapy ought to be given.

Finally, this study adds yet more evidence to the idea that, ultimately, the best and ultimate treatment of CAD will turn out to be medical (such as accomplished with drugs and lifestyle changes) rather than surgical or catheter-based. In fact, enough evidence already justifies urging you -- and any patient with CAD -- to engage in a personal Manhattan Project of risk factor modification. Evidence is piling up that, even without any further advances in medical science, enough tools are available to you to halt (or potentially, begin to reverse) the atherosclerotic process that, until recently, looked invariably like a chronically progressive disease.


Chhatriwalla AK, Nicholls SJ, Wang TH, et al. Low levels of low-density lipoprotein cholesterol and blood pressure and progression of coronary atherosclerosis. J Am Coll Cardiol 2009; 53: 1110-1115.

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