By Tim Bonfield
Enquirer staff writer

Many more people at high risk for heart attacks will be urged to start taking cholesterol-lowering drugs and many others who already take such drugs may be getting higher doses as doctors react to new cardiac treatment guidelines.

WHO'S AT RISK?

People at high risk for a heart attack include those who have already had heart attacks, people who have been treated with angioplasties or coronary bypass surgeries, people with diabetes especially in combination with smoking, obesity or poorly controlled high blood pressure, and people with "metabolic syndrome," a mix of obesity, high triglycerides and low levels of "good" HDL cholesterol. Measuring risk: To calculate your chances of heart disease in the next 10 years, check the Web site for the National Heart, Lung and Blood Institute. Click on "Health Assessment Tools" to find the "10-Year Heart Attack Risk Calculator."

"High-risk" heart patients should reduce their LDL or "bad cholesterol" level to 70 or lower, according to standards published in Circulation, a leading medical journal for heart disease.

That's a sharp reduction from the previous goal for such patients: an LDL reading of 100 or less.

Yet doctors and insurers said Tuesday that many high-risk heart patients weren't meeting the old goal. That means millions of Americans, including thousands in Greater Cincinnati and Northern Kentucky, will need to take even higher doses of medications to reach the new goal.

"The message is, the lower the LDL the better. Exercise and diet alone will not be enough for these people," said Dr. Dean Kereiakes, of Ohio Heart Health Center.

People at high risk for heart attack include those who have already had heart attacks - about 7.8 million people nationwide - and people with clogged arteries who have been treated with angioplasties or bypass surgeries, and people with combinations of other risk factors.

The group gets bigger each year as another 1.2 million people suffer new heart attacks, according to the American Heart Association.

The primary way to reduce high LDL is to prescribe one of several statin drugs, such as Lipitor, Zocor, Pravachol or Crestor.

Some patients also have received statin-boosting drugs, such as Zetia, which can speed the reduction of plaque build-up in arteries.

But recent studies have shown that many people who should be taking such drugs aren't.

Among members of 300 HMOs nationwide, only 61 percent of people with high cholesterol had their condition under proper control, according to a 2003 report from the National Committee for Quality Assurance.

"These standards are overdue, in my opinion. Studies have shown that every reduction in LDL has led to a reduction in heart attack risk," said Dr. Joel Reginelli, an interventional cardiologist with the Cardiology Center of Cincinnati.

So why aren't more people getting treated?

It's not a lack of coverage from private insurance companies. Officials with United Healthcare, Anthem and Humana, the three largest in Greater Cincinnati, said they support the new standards. They already cover most statin drugs. .

"This is a no-brainer," said Dr. Barry Malinowski, southwest Ohio medical director for Anthem. "We know that the more people who have LDLs under 100, the fewer people have heart attacks. With the standards even lower, I don't think we'll have any problems endorsing those."

Some doctors are much less aggressive than others about prescribing statins, Reginelli said.

"With higher doses, there is some increased risk of liver damage, but with close monitoring, this is still a safe approach," he said.

Even so, many doctors make prescriptions for statins that never get filled, Malinowski said.

Part of the explanation for that includes the historic lack of drug coverage from Medicare, which can make the medications expensive for seniors.

But now, a variety of discount-drug cards are available and in 2006 a new prescription-drug plan for Medicare kicks in.

But often, the lack of cholesterol control traces back to the patients, Malinowski said.

For some, medications can't do the job by themselves.

"This isn't about just putting people on Lipitor or some other statin and saying, 'You're fine now,' " Malinowski said. "People also still need to make lifestyle changes, and those can be challenging."

E-mail tbonfield@enquirer.com