Is a lower cholesterol or A1c necessarily better?

Two major events in 2008 tests these assertions.

First, the ENHANCE trial showed that while the combination of simvastatin and ezetimibe lowered cholesterol, it did not slow the progression of atherosclerosis.

Next, the ACCORD study concluded that a hemoglobin A1c target of less than 6% was associated with an increased mortality, ending that particular arm of the trial.

MedPage Today includes these stories among others in their 2008 roundup of top medical stories.

Comments

Dr. Matthew Mintz
One of the reasons I blog is to clear up confusion some patients have from large studies reported in the media.
The ENHANCE trial didn’t demonstrate that lower wasn’t better, it demonstrated that in the particular population chosen, preventing atherosclerosis progession by adding zetia to simvastatin (Vytorin), was no better than simvastatin alone. There is tons of evidence that more you lower ldl (bad cholesterol) WITH A STATIN, the more you decrease risk for heart attacks. Thus, ENHANCE showed us there may be more to it than just lowering LDL. The JUPITER trial also published this year was further evidence of this, given patient’s LDL and risk wouldn’t have warranted statin therapy by current guidelines, but with a high CRP, their risk of heart attack was substantially reduced with Crestor 20mg.
Similarly, the ACCORD study did not show that lower A1c wasn’t better. What keeps getting missed is that both groups in the study did much better (fewer heart attacks, deaths) than usual care. ACCORD showed that 1) it is difficult to show an INDEPENDENT heart attack benefit by lowering blood sugar when so many other factors (like cholesterol) are important and 2) going too low (A1c of 6%) might be harmful. In the upcoming January 2009 issue of Diabetes Care , the ADA and AHA do a great job of explaining how to interpret these results, and continue to recommend and A1c of less that 7% for diabetics.
One issue is again the fact that blood pressure and cholesterol also have important roles in diabetes. In fact, the SANDS study also published this year showed that atherosclerosis progression could be prevented with agressive blood pressure and cholesterol lowering in Type 2 diabetics, including the use of Zetia (half of Vytorin).

Is a lower cholesterol or A1c necessarily better?

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