I would like to update a letter to the editor that I wrote some years ago. In that letter I stated that
even though I treated your cholesterol to plaque regression levels, you might still have an
atherothrombotic disease (ATD) event on down the line. A new study, albeit done in mice, has prompted me
to re-think matters.
What I wrote back then is true for people whose ATD is already far advanced when treatment of their
cholesterol levels is initiated. The plaque is 1/3 composed with cholesterol and 2/3 composed of fibrous
tissue. Treatment of cholesterol to plaque stabilization/regression levels shrinks the cholesterol
content of the plaque, but can do nothing to shrink the fibrous content of the plaque. The shrunken
plaque, however, still creates turbulence in the flow of blood and more fibrous tissue is laid down to
"smooth over" the plaque remnants.
This fibrous tissue can continue to build till sufficient blood is unable to flow over the plaque and
ischemia (lack of oxygen) results. This in turn may cause chest pain or other equivalent symptom such as
shortness of breath on walking or climbing stairs – but it, to all intents and purposes, will not cause
a heart attack.
And such ATD symptoms rarely need surgery, despite what an angiographer might tell you, unless the
symptoms are incapacitating.
On the other hand, if treatment of cholesterol disorders is begun early enough, those advanced plaques do
not form and the above scenario does not play out. Then again, no one wants to treat every one for
something (an ATD event such as a heart attack or stroke) that is not likely to occur for decades. The
trick is to figure out whom to treat and when to begin treatment of cholesterol disorders. (Of course,
cigarette smoking has to be stopped and the sooner the better.)
That’s why I have recommended screening children and young adults. Such screening tells me when "the
clock starts to tick" and hence when I need to initiate treatment. Otherwise it’s a guess – though
the worse the cholesterol disorder, the sooner I need to start therapy. ATD events do not need to happen
but if they do (because treatment was initiated when the plaque was already advanced) they need not
necessarily be major events. Get your ATD risk assessment from your family doctor now.
William E. Feeman, Jr., M.D.
Bowling Green