Live Healthier, Live Longer
Lowering Cholesterol for the Person With Heart Disease


National Cholesterol Education Program

NATIONAL INSTITUTES OF HEALTH
NATIONAL HEART, LUNG, AND BLOOD INSTITUTE





__________________________________________________________
Live Healthier, Live Longer--

Lowering Cholesterol for the Person With Heart Disease


If you have coronary heart disease (CHD), paying attention
to your cholesterol level could well save your life.  Read
this booklet to find out how and why.


National Cholesterol Education Program
__________________________________________________________





TABLE OF CONTENTS

CORONARY HEART DISEASE 

What Is Coronary Heart Disease? 
How Do You Know If You Have Coronary Heart Disease?

ROLE OF CHOLESTEROL IN CHD

Lipoproteins
What Makes Blood Cholesterol High or Low? 
Unstable Plaque
The Benefits of Cholesterol Lowering
Persons With CHD Have a Lower Goal Cholesterol Level
Getting To Know Your Risk Factors for Coronary Heart Disease

HOW DO I FIND OUT MY CHOLESTEROL LEVEL? 

TREATMENT SUMMARY

IMPROVE YOUR DIET

Practical Ways To Change Your Diet
Read Food Labels
How Soon Will You See Results?
How Much Cholesterol Reduction Can You Expect?
Lifetime Changes in Diet

BECOME MORE PHYSICALLY ACTIVE 

LOSE WEIGHT IF YOU ARE OVERWEIGHT

CHOLESTEROL-LOWERING MEDICINES

Statins
Bile Acid Resins
Nicotinic Acid
Other Drugs
      Fibrates
      Hormone Replacement Therapy
Combination Drug Therapy

OTHER MEDICATIONS COMMONLY PRESCRIBED FOR CHD

NEXT STEPS

Talk to Your Doctor--Be Part of Your Health Care Team
Get Support
Long-Term Monitoring
Maintaining Healthy Behaviors and Overcoming Relapse
      Eat Right at Social Events
      Eating Out
      How To Stay on Your Cholesterol-Lowering Medication

QUESTIONS YOU MAY BE WONDERING ABOUT

GET MORE INFORMATION

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Live Healthier, Live Longer--

Lowering Cholesterol for the Person With Heart Disease


CORONARY HEART DISEASE

If you have coronary heart disease (CHD), there are some
important things for you to know.  They could save your
life.

Twelve to thirteen million American adults have CHD, which
is a major cause of disability and the number one killer of
women and of men in the United States.  In 1994, almost
500,000 people died from CHD, equally divided between men
and women.  About 1.25 million people have heart attacks
every year, and about half of these occur in persons who are
already known to have CHD.  For men and women with CHD, the
risk of a heart attack is five to seven times higher than
for people of the same age and sex who do not have CHD.

If you have CHD, that's the bad news.  But the good news is
that by lowering your cholesterol you can reduce your risk
of having a heart attack.  This booklet was written to help
you make healthy changes in your life that can reduce your
risk.

I Already Have Heart Disease.  Is It Too Late To Reduce My
Risk?

No, it's not too late to help your heart.  Most CHD patients
will benefit from cholesterol lowering.  In fact, if you
already have heart disease, you should pay even more
attention to your cholesterol level, because you stand to
benefit even more.  A person with CHD has a much greater
risk of having a future heart attack than a person without
heart disease.  If you lower your blood cholesterol level,
you will definitely reduce your risk of a future heart
attack and could actually prolong your life.

What Is Coronary Heart Disease?

You probably know that CHD is a type of heart disease caused
by narrowing of the coronary arteries that feed the heart. 
Like any muscle, the heart needs a constant supply of oxygen
and nutrients, which are carried to it by the blood in the
coronary arteries.  When the coronary arteries become
narrowed or clogged by fat and cholesterol deposits and
cannot supply enough blood to the heart, the result is CHD. 
If not enough oxygen-carrying blood reaches the heart, the
person may experience chest pain called angina.  If the
blood supply to a portion of the heart is completely cut off
by total blockage of a coronary artery, the result is a
heart attack.  This is usually due to a sudden closure from 
a blood clot forming on top of a previous narrowing.

How Do You Know If You Have Coronary Heart Disease?

If you answer yes to any of these questions, you most
probably have CHD.

--  Have you ever had a heart attack?

--  Do you suffer from chest pain that has been diagnosed as
    angina?

--  Have you had heart surgery such as a bypass operation or
    a balloon or angioplasty procedure?

--  Have you ever had an angiogram (a special x-ray picture
    of the heart) that showed a blockage in your coronary
    arteries?

You should be sure to talk to your doctor about cholesterol
if you have answered yes to any of these questions.


ROLE OF CHOLESTEROL IN CHD

What is cholesterol and what does it have to do with CHD? 
Cholesterol is a waxy substance that occurs naturally in all
parts of the body and that your body needs to function
normally.  It is present in cell walls or membranes
everywhere in the body, including the brain, nerves, muscle,
skin, liver, intestines, and heart.  Your body uses
cholesterol to produce many hormones, vitamin D, and the
bile acids that help to digest fat.  It takes only a small
amount of cholesterol in the blood to meet these needs. 
However, if you have too much cholesterol in your
bloodstream, it can lead to atherosclerosis, a condition in
which fat and cholesterol are deposited in the walls of the 
arteries in many parts of the body, including the coronary
arteries feeding the heart.  In time, narrowing of the
coronary arteries by atherosclerosis can produce the signs
and symptoms of CHD, including angina and heart attack.

Lipoproteins

Cholesterol travels in the blood in packages called
lipoproteins.  Just like oil and water, cholesterol, which
is fatty, and blood, which is watery, do not mix.  In order
to be able to travel in the bloodstream, the cholesterol
made in the liver is combined with protein, making a
lipoprotein.  This lipoprotein then carries the cholesterol
through the bloodstream.

There are specific kinds of lipoproteins that contain
cholesterol in your blood, and each affects your heart
disease risk in a different way.

*  Low density lipoproteins (LDLs):  the "bad" cholesterol. 
   LDLs carry most of the cholesterol in the blood, and the
   cholesterol from LDLs is the main source of damaging
   buildup and blockage in the arteries.  Thus, the more
   LDL-cholesterol you have in your blood, the greater your
   risk of CHD.  If you have CHD and your LDL is higher than
   100 mg/dL, your cholesterol may well be too high for
   you.

*  High density lipoproteins (HDLs):  the "good"
   cholesterol.  HDLs carry cholesterol in the blood from
   other parts of the body back to the liver, which leads to
   its removal from the body.  So HDLs help keep cholesterol
   from building up in the walls of the arteries.  If your
   level of HDL-cholesterol is below 35 mg/dL, you are at
   substantially higher risk for CHD.  The higher your HDL-
   cholesterol, the better.  The average HDL-cholesterol
   for men is about 45 mg/dL, and for women it is about 55
   mg/dL.

*  Triglycerides:  a form of fat carried through the
   bloodstream.  Most of your body's fat is in the form of
   triglycerides stored in fat tissue.  Only a small portion
   of your triglycerides is found in the bloodstream.  High
   blood triglyceride levels alone do not cause
   atherosclerosis.  But lipoproteins that are rich in
   triglycerides also contain cholesterol, which causes
   atherosclerosis in some people with high triglycerides. 
   So high triglycerides may be a sign of a lipoprotein
   problem that contributes to CHD.

What Makes Blood Cholesterol High or Low?

Your blood cholesterol level is affected not only by what
you eat but also by how quickly your body makes LDL-
cholesterol and disposes of it.  In fact, your body makes
all the cholesterol it needs, and it is not necessary to
take in any additional cholesterol from the foods you eat.

Patients with CHD typically have too much LDL-cholesterol in
their blood.  Many factors help determine whether your LDL-
cholesterol level is high or low.  The following factors are
the most important:

*  Heredity.  Your genes influence how high your LDL-
   cholesterol is by affecting how fast LDL is made and
   removed from the blood.  One specific form of inherited
   high cholesterol that affects 1 in 500 people is familial
   hypercholesterolemia, which often leads to early CHD. 
   But even if you do not have a specific genetic form of
   high cholesterol, genes play a role in influencing your
   LDL-cholesterol level.

*  What you eat.  Two main nutrients in the foods you eat
   make your LDL-cholesterol level go up:  saturated fat, a
   type of fat found mostly in foods that come from animals;
   and cholesterol, which comes only from animal products. 
   Saturated fat raises your LDL-cholesterol level more than
   anything else in the diet.  Eating too much saturated fat
   and cholesterol is the main reason for high levels of
   cholesterol and a high rate of heart attacks in the
   United States.  Reducing the amount of saturated fat and
   cholesterol you eat is a very important step in reducing
   your blood cholesterol levels.

*  Weight.  Excess weight tends to increase your LDL-
   cholesterol level.  If you are overweight and have a
   high LDL-cholesterol level, losing weight may help you
   lower it.  Weight loss also helps to lower triglycerides
   and raise HDL.

*  Physical activity/exercise.  Regular physical activity
   may lower LDL-cholesterol and raise HDL-cholesterol
   levels.

*  Age and sex.  Before menopause, women usually have total
   cholesterol levels that are lower than those of men the
   same age.  As women and men get older, their blood
   cholesterol levels rise until about 60 to 65 years of
   age.  In women, menopause often causes an increase in
   their LDL-cholesterol and a decrease in their HDL-
   cholesterol level, and after the age of 50, women often
   have higher total cholesterol levels than men of the same
   age.  Some women may benefit from hormone replacement
   therapy (also called estrogen replacement therapy) after
   menopause, because estrogen lowers LDL and raises HDL.

*  Alcohol.  Alcohol intake increases HDL-cholesterol but
   does not lower LDL-cholesterol.  Doctors don't know for
   certain whether alcohol also reduces the risk of CHD. 
   Drinking too much alcohol can damage the liver and heart
   muscle, lead to high blood pressure, and raise
   triglycerides.  Because of the risks, alcoholic beverages
   should not be used as a way to prevent CHD.

*  Stress.  Stress over the long term has been shown in
   several studies to raise blood cholesterol levels.  One
   way that stress may do this is by affecting your habits. 
   For example, when some people are under stress, they
   console themselves by eating fatty foods.  The saturated
   fat and cholesterol in these foods contribute to higher
   levels of blood cholesterol.

Unstable Plaque

Cholesterol is a major ingredient of the plaque that builds
up in the coronary arteries and causes CHD, so it is
important to understand how plaques develop.  Excess
cholesterol is deposited in the artery walls as it travels
through the bloodstream.  Then, special cells in the artery
wall gobble up this excess cholesterol, creating a "bump" in
the artery wall.  This cholesterol-rich "bump" then is
covered by a scar that produces a hard coat or shell over
the cholesterol and cell mixture.  It is this collection of
cholesterol covered by a scar that is called plaque.

The plaque buildup narrows the space in the coronary
arteries through which blood can flow, decreasing the supply
of oxygen and nutrients to the heart.  If not enough oxygen-
carrying blood can pass through the narrowed arteries to
reach the heart muscle, the heart may respond with a pain
called angina.  The pain usually happens with exercise when
the heart needs more oxygen.  It is typically felt in the
chest or sometimes in other places like the left arm and
shoulder.  However, this same inadequate blood supply may
cause no symptoms.

Plaques come in various sizes and shapes.  Throughout the
coronary arteries many small plaques build themselves into
the walls of the arteries, blocking less than half of the
artery opening.  These small plaques are often invisible on
many of the tests doctors use to identify coronary heart
disease.  It used to be thought that the most dangerous
plaques and the ones most likely to cause total blockage of
coronary arteries were the largest ones.  The largest
plaques are in fact the ones most likely to cause angina. 
However, small plaques that are full of cholesterol but not
completely covered by scar are now thought to be very
unstable and more likely to rupture or burst, releasing
their cholesterol contents into the bloodstream.

When this happens, it triggers blood clotting inside the
artery.  If the blood clot totally blocks the artery, it
stops blood flow and a heart attack occurs.  The muscle on
the far side of the blood clot does not get enough oxygen
and begins to die.  The damage can be permanent.

Lowering your blood cholesterol level can slow, stop, or
even reverse the buildup of plaque.  Cholesterol lowering
can reduce your risk of a heart attack by lowering the
cholesterol content in unstable plaques to make them more
stable and less prone to rupture.  This is why lowering your
LDL-cholesterol is such an important way to reduce your risk
for having a heart attack.  Even in people who have had one
heart attack, the chances of having future attacks can be
substantially reduced by cholesterol lowering.

The Benefits of Cholesterol Lowering

A 1994 study called the Scandinavian Simvastatin Survival
Study (also called 4S) found that lowering cholesterol can
prevent heart attacks and reduce death in men and women who
already have heart disease and high cholesterol.  For over 5
years, more than 4,400 patients with heart disease and total
cholesterol levels of 213 mg/dL to 310 mg/dL were given
either a cholesterol-lowering drug or a placebo (a dummy
pill that looks exactly like the medication).  The drug they
were given is known as a statin, and it reduced total 
cholesterol levels by 25 percent and LDL-cholesterol levels 
by 35 percent.  The study found that in those receiving 
statin, deaths from heart disease were reduced by 42 percent,
the chance of having a nonfatal heart attack was reduced by 
37 percent, and the need for bypass surgery or angioplasty 
was reduced by 37 percent.  A very important finding is that
deaths from causes other than cardiovascular disease were not
increased, and so the 42 percent reduction in heart disease
deaths resulted in a 30 percent drop in overall deaths from 
all causes.

The 4S researchers say that the following benefits could be
expected if doctors were to treat their heart disease
patients for the same 5-year period and lower cholesterol to
the same extent.  For every 1,000 patients:

*  40 people would be saved out of the 90 who would
   otherwise die from heart disease.

*  70 of the expected 210 nonfatal heart attacks would be
   avoided.

*  Heart procedures such as bypass surgery would be avoided
   in 60 of the 210 patients who would be expected to need
   these procedures.

In 1996 the results of the Cholesterol and Recurrent Events
(CARE) Study also showed the benefits of cholesterol
lowering in CHD patients.  This study reported that even in 
patients with seemingly normal cholesterol levels (average
of 209 mg/dL), cholesterol lowering with a statin drug
lowered the risk of having another heart attack or dying by
24 percent.  These patients were also less likely to need
bypass surgery (26 percent reduction) or angioplasty (22
percent reduction) during the study.  Women benefited even
more than men, reducing their risk of having another heart
attack by 45 percent.  The CARE researchers estimate that
treatment of 1,000 patients similar to those in CARE would
result in 153 fewer heart attacks and deaths from heart
disease.  If the patients were over 60, there would be 214
fewer, and if they were all women, there would be 248 fewer.

These studies along with many others support the need to
lower cholesterol levels in CHD patients.  If you lower your
cholesterol, you too can see benefits like those in 4S and
CARE.   

Persons With CHD Have a Lower Goal Cholesterol Level

For the general population, a level of LDL-cholesterol below
130 mg/dL is called desirable.  But if you have CHD, your
goal is lower:  You should reduce your LDL-cholesterol to
about 100 mg/dL or less.  This is because patients with CHD,
even if they have relatively low cholesterol levels (say an
LDL-cholesterol of 120 mg/dL), have shown that they are
susceptible to developing CHD at that level.  A recent study
has reaffirmed the benefit of lowering LDL-cholesterol
levels in CHD patients to 100 mg/dL or less.  So, if you
have CHD and your LDL-cholesterol level is more than 100
mg/dL, it may well be too high for you.

Getting To Know Your Risk Factors for Coronary Heart Disease

In addition to a high total and LDL-cholesterol level and a
low HDL-cholesterol level, other factors also increase your
chance of CHD complications.  The box below lists risk
factors you can do something about.  The more of these
modifiable risk factors you have, the higher your chance of
having another heart attack or worsening your CHD.  

MODIFIABLE RISK FACTORS FOR HEART DISEASE

*  High total cholesterol and high LDL-cholesterol

*  Low HDL-cholesterol

*  Cigarette smoking

*  High blood pressure

*  Diabetes

*  Obesity/overweight

*  Physical inactivity

You can reduce your risk of having another heart attack or
other CHD problem by doing something about your modifiable
risk factors.  This means that, in addition to controlling
your cholesterol level, you should make a major effort to
stop smoking, control your high blood pressure, lose weight
if you are overweight, and increase your physical activity. 
Controlling high blood sugar if you have diabetes is
important too.

Smoking.  Cigarette smoking is a strong risk factor for CHD. 
Stopping smoking reduces your risk for CHD and stroke,
beginning with the first year after stopping smoking.  It
also reduces your chances of getting lung cancer and other
cancers and chronic lung disease.  Changing to low-tar or
low-nicotine cigarettes does not reduce the risk for CHD.

High blood pressure.  High blood pressure (or hypertension)
is associated with increased rates of CHD, as well as stroke
and kidney failure.  Treatment of hypertension reduces your
risk for all these complications.

Diabetes.  Diabetes, whether insulin dependent or non-
insulin dependent, increases the risk for CHD.  In men,
diabetes increases risk for CHD complications by about three
times, and the increase in risk may be even greater for
women.

Obesity.  Obesity or overweight increases the risk for CHD
in men and women.  If you are overweight, losing weight can
improve other risk factors including diabetes, high blood
pressure, and cholesterol, making weight loss very important
in the treatment of CHD.

Physical inactivity.  Physical inactivity can increase your
risk for CHD.  Regular physical activity can reduce LDL-
cholesterol, triglycerides, high blood pressure, and weight
while raising HDL-cholesterol and improving the fitness of
your heart and lungs.  Regular physical activity is
recommended to reduce your risk of future CHD complications.


HOW DO I FIND OUT MY CHOLESTEROL LEVEL?

Since you have heart disease, finding out your blood
cholesterol should be done by a blood test called a
lipoprotein profile.  This test will determine not only your
total and HDL-cholesterol levels, but also your LDL-
cholesterol and triglyceride levels.  In order to take the
test, you must fast, usually overnight.  That means you may
have nothing to eat or drink but water (or black coffee or
tea with no milk, cream, or sugar) for 9 to 12 hours
beforehand.

When you get your lipoprotein profile report from your
doctor, there are several numbers you should look at:  total
cholesterol, LDL-cholesterol, HDL-cholesterol, and
triglycerides.  The important thing to remember is that your
doctor will decide on the best treatment for you based
primarily on your LDL level.  The decision to start
treatment should be based on the average of two LDL tests
taken 1 to 8 weeks apart.  The goal of treatment for CHD
patients should be an LDL of about 100 mg/dL or less, which 
is a lower target level than for people who do not have
heart disease.

HDL-cholesterol is important to know too.  If your HDL is
less than 35 mg/dL, your doctor will try to help you raise
it, while lowering LDL-cholesterol.


TREATMENT SUMMARY

If you have CHD, one of the keys to reducing the risk for
future heart attacks or other CHD complications is to lower
your LDL-cholesterol.  The goal LDL-cholesterol for CHD
patients is a level of about 100 mg/dL or less.  You can
lower LDL-cholesterol through changes in life habits: 
decreasing saturated fat and cholesterol in the diet,
increasing physical activity, and controlling body weight. 
In addition, medications are available to help you lower
your LDL-cholesterol level.  For many patients it is
necessary to combine medications with changes in life habits
to get enough of a reduction in LDL-cholesterol, especially
to reach the optimum level of 100 mg/dL or less.  Your
doctor can help to decide which combination of cholesterol-
lowering activities is right for you.

Four steps you can take to reduce your high blood
cholesterol:

*  Follow the Step II diet (low saturated fat, low
   cholesterol).

*  Be more physically active.

*  Lose weight if you are overweight.

*  Take your cholesterol-lowering medication if prescribed
   by your doctor.

Even if your doctor starts you on a cholesterol-lowering
drug, it is important for you to adopt heart-healthy life
habits.  These will help to bring about a bigger drop in
your LDL-cholesterol, and they will reduce your risk for
future CHD in other ways as well.  It is not enough just to
take a drug.  If you do only that, you will fail to get the
full amount of risk reduction that is possible. 
Cholesterol-lowering drugs can significantly decrease your
risk for future CHD, but you will do even better by
modifying your life habits in addition.

What Your LDL-Cholesterol Means To You*

If you have heart disease      You do not need to take 
and your LDL-cholesterol       specific steps to lower your
is 100 mg/dL or less:          LDL, but you will need to
                               have your level tested again
                               in 1 year.  In the meantime,
                               you should closely follow a
                               diet low in saturated fat and
                               cholesterol, maintain a       
                               healthy weight, be physically
                               active, and not smoke.  You
                               should also follow the
                               medical regimen prescribed by
                               your doctor.

If you have heart disease      You need to have a complete
and your LDL-cholesterol       physical examination done to
level is greater than          see if you have a disease or
100 mg/dL:                     a health condition that is
                               raising your cholesterol
                               levels.  You will need to
                               follow the Step II diet (see
                               page 12), which is low in
                               saturated fat and
                               cholesterol, and be
                               physically active, lose
                               weight if you are overweight,
                               and not smoke.  If your LDL
                               level remains too high, you
                               may need to take medication.

*For anyone 20 years of age or older


IMPROVE YOUR DIET

A diet lower in saturated fat and cholesterol than the
average American diet is a healthy way for the whole family
to eat (except infants under 2 years who need more calories 
from fat).  Since you have heart disease and need to lower
your blood cholesterol level more than someone who does not
have heart disease, you will probably be advised by your
doctor to follow a Step II diet, which is lower in saturated
fat and cholesterol than the diet the rest of your family
may wish to follow.  Because this Step II diet may include
many changes to your current eating plan, your doctor may
refer you to a registered dietitian who can help you make
these changes.

On the Step II diet, you should eat:

*  Less than 7 percent of the day's total calories from 
   saturated fat.

*  30 percent or less of the day's total calories from fat.

*  Less than 200 milligrams of dietary cholesterol a day.

*  Just enough calories to achieve and maintain a healthy
   weight.  (Ask your doctor or registered dietitian what is
   a reasonable calorie level for you.)

The recommendations for saturated fat and total fat are
based on a percentage of the total calories you eat; the
actual amount you can eat daily will vary depending on how
many total calories you eat.  See the chart below to get an
idea of the number of grams of saturated fat and total fat
you should be eating.

Step II Recommendations for Saturated Fat and Total Fat
According to Total Calorie Level

Total Calories          1,200  1,500  1,800  2,000  2,500
Saturated fat (grams)*    8      10     12     13     17
Total fat (grams)**      40      50     60     65     80

 *  One gram of fat equals 9 calories.  Amounts are equal to
    6 percent of total calories for Step II; your intake
    should be this much or less.

**  Amounts are equal to 30 percent of total calories
    (rounded down to the nearest 5).

NOTE:  On average, women consume about 1,800 calories a day
       and men consume about 2,500 calories a day.

Next, here are some general ways to lower blood cholesterol
through your diet:

*  Choose foods low in saturated fat.

All foods that contain fat have different mixtures of
saturated and unsaturated fats.  Saturated fat raises your
blood cholesterol level more than anything else that you
eat.  It is found in greatest amounts in foods from animals,
such as fatty cuts of meat, poultry with the skin, whole-
milk dairy products, and lard, and in tropical oils like
coconut, palm kernel, and palm oils.  Most other vegetable
oils are low in saturated fats.  The best way to reduce your
blood cholesterol level is to choose foods low in saturated
fat.  One way to do this is by choosing foods such as fruit,
vegetables, and whole grain foods, which are naturally low
in fat and high in starch and fiber.  You should read the
food labels in the grocery store to help you choose foods
that are low in saturated fat (see page 16).

*  Choose foods low in total fat.

Since many foods high in total fat are also high in
saturated fat, eating foods low in total fat will help you
eat less saturated fat.  Any type of fat is a rich source of
calories, so eating foods low in fat should also help you
eat fewer calories, which will help you lose weight.  If you
are overweight, losing weight is an important part of
lowering your blood cholesterol.  When you do eat fat, you
should substitute unsaturated fat for saturated fat. 
Unsaturated fat can be either monounsaturated or
polyunsaturated.  Examples of foods high in monounsaturated
fat are olive and canola oils.  Those high in
polyunsaturated fats are safflower, sunflower, corn, and
soybean oils.  The food label is your best guide to how much
total fat, saturated fat, and unsaturated fat and how many
calories are in the foods you buy (see page 16).

*  Choose foods low in cholesterol.

Dietary cholesterol also can raise your blood cholesterol
level, although usually not as much as saturated fat.  So it
is important to choose foods low in dietary cholesterol. 
Dietary cholesterol is found only in foods that come from
animals.  Many of these foods also are high in saturated
fat.  Foods from plant sources do not have cholesterol but
can contain saturated fat.  Use the food label when shopping
to choose foods low in cholesterol.

*  Choose foods high in starch and fiber.

Foods high in starch and fiber are excellent substitutes for
foods high in saturated fat.  These foods--breads, cereals,
pasta, grains, fruits, and vegetables--are low in saturated
fat and cholesterol, unless fat is added in their
preparation.  They are also usually lower in calories than
foods that are high in fat.  Foods high in starch and fiber
are also good sources of vitamins and minerals.

*  A word about sodium.

If you have high blood pressure as well as high blood
cholesterol (and many people do), your doctor may tell you
to cut down on sodium or salt.  As long as you are working
on getting your blood cholesterol number down, this is a
good time to work on your blood pressure, too.  Try to limit
your sodium intake to 2,400 milligrams a day.

Practical Ways To Change Your Diet

Here are some tips on how to choose foods for the Step II
diet.

To cut back on saturated fats, choose:

*  Poultry, fish, and lean cuts of meat.  Remove the skin
   from chicken and trim the fat from meat before cooking.

*  Skim or 1 percent milk instead of 2 percent or whole
   milk.

*  Cheeses with no more than 3 grams of fat per ounce (these
   include low-fat cottage cheese or other low-fat cheeses).
   Cut down on full-fat processed, natural, and hard cheeses
   (like American, brie, and cheddar).

*  Low-fat or non-fat yogurt, sour cream, and cream cheese
   instead of the high-fat varieties.

*  Liquid vegetable oils that are high in unsaturated fat
   (these include canola, corn, olive, and safflower oil).

*  Margarine made with unsaturated liquid vegetable oil as
   the first ingredient rather than hydrogenated or
   partially hydrogenated oil.  Choose tub or liquid
   margarine or vegetable oil spreads.  The softer the
   margarine, the more unsaturated it is.  If you are
   watching your sodium intake, try unsalted margarine.  Use
   the food label to choose margarines with the least amount
   of saturated fat.

*  Fewer commercially prepared and processed foods made with
   saturated or hydrogenated fats or oils (like cakes,
   cookies, and crackers).

*  Foods high in starch and fiber such as whole wheat breads
   and cereals instead of foods high in saturated
   fats.

Cutting back on saturated fat helps you to control dietary
cholesterol as well, because cholesterol and saturated fat
are often, but not always, found together in the same foods. 
Two additional points to remember when cutting back on
dietary cholesterol are:

*  Strictly limit organ meat (such as liver, brain, and
   kidney).

*  Eat a total of two or fewer egg yolks a week (as whole
   eggs or in prepared foods).  Try substituting two egg
   whites for each whole egg in recipes, or using an egg
   substitute.

To include more foods high in starch and fiber, choose:

*  More vegetables and fruits.  It is recommended that
   Americans eat five servings of fruits and vegetables
   every day.  They are low in saturated fat and total fat
   and have no cholesterol.  Fruits and vegetables are good
   sources of starch, fiber, vitamins, and minerals and are
   low in sodium.  They are also low in calories (which
   helps with weight control) except for avocados and
   olives, which are high in both fat and calories.  Many
   fruits and vegetables are also high in vitamin C, vitamin
   E, and beta-carotene--so-called "antioxidants."  A diet
   high in these fruits and vegetables may also help to
   lower risk for heart disease.  So fruits and vegetables
   are great substitutes for foods high in saturated fat and
   cholesterol.

*  Whole grain breads and cereals, pasta, rice, and dry peas
   and beans.

You should also cook the low-fat way:

*  Bake, broil, microwave, poach, or roast instead of
   breading and frying.

*  When you roast, place the meat on a rack so the fat can
   drip away.

Read Food Labels

We've already mentioned that reading food labels will help
you choose foods low in saturated fat, total fat,
cholesterol, and calories.  Food labels have two important
parts:  nutrition information and an ingredients list.

Read the nutrition information.

Look for the amount of saturated fat, total fat,
cholesterol, and calories in a serving of the product. 
Compare similar products to find the one with the least
amounts.  If you have high blood pressure, do the same for
sodium.

Look at the ingredients.

All food labels list the product's ingredients in order by
weight.  The ingredient in the greatest amount is listed
first.  The ingredient in the least amount is listed last. 
So, to choose foods low in saturated fat or total fat, limit
your use of products that list any fat or oil first--or that
list many fat and oil ingredients.  If you are watching your
sodium intake, do the same for sodium or salt.

------------------------------------------------------------
Graphic Missing

Nutrition Fact Food Label
------------------------------------------------------------

How Soon Will You See Results?

Generally your blood cholesterol level should show a drop a
few weeks after you start on the Step II diet.  LDL-
cholesterol levels should be measured after being on the
diet for 3 to 4 weeks.  You should set up a schedule for
followup cholesterol measurements with your doctor.  This
schedule will depend on your specific cholesterol level and 
management program.  If your LDL is still too high, your
doctor may want you to begin cholesterol-lowering medicine. 
Once you have reached your goal for LDL-cholesterol, long-
term monitoring can begin.

How Much Cholesterol Reduction Can You Expect?

How effective diet is in lowering your LDL-cholesterol level
depends on your dietary habits before starting the diet, how
well you follow your diet, and how your body responds to
your new way of eating.  In general, those with higher
cholesterol levels have greater reductions in LDL-
cholesterol levels than those with lower starting levels. 
If you are overweight and lose weight, a low-fat diet may
work even better to lower your high cholesterol.

Dietary equations predict that the Step II diet can reduce
total cholesterol levels in CHD patients who are consuming
an average American diet by about 8 to 14 percent.  Many
people with CHD and elevated cholesterol levels consume more
saturated fat and cholesterol and have higher blood
cholesterol levels than average and will have an even bigger
reduction.  Every 1 percent reduction in cholesterol levels
lowers your risk for a future heart attack by about 2
percent.  So an 8 to 14 percent reduction in cholesterol
levels from the Step II diet would lower the CHD risk by
about 16 to 28 percent.

Lifetime Changes in Diet

Many people find that advice from a registered dietitian or
other qualified nutritionist can help them to be more
successful with the Step II diet.  Whoever prepares the
meals in your house should also participate in these
sessions.  Your new diet should be maintained for life.  You
may want to continue diet education sessions with your
dietitian quarterly for the first year of long-term
monitoring and twice yearly thereafter.

In addition to making changes in the way you eat, there are
other changes you should make.


BECOME MORE PHYSICALLY ACTIVE

Regular physical activity by itself may help reduce deaths
from heart disease by:

*  Lowering LDL levels

*  Raising HDL levels

*  Lowering high blood pressure

*  Lowering triglyceride levels

*  Reducing excess weight

*  Improving the fitness of your heart and lungs

Since you have heart disease, talk with your doctor before
starting an activity to be sure you are following a safe
program that works for you.

Your doctor will recommend an activity program to meet your
needs.  If you have been inactive for a long time, you will
be instructed to start with low-to-moderate level activities
such as walking, taking the stairs instead of the elevator,
gardening, housework, dancing, or exercising at home.  Begin
by doing the activity for a few minutes most days.  Your
doctor will then increase your activity level, allowing you
to work up to a longer program--your goal is at least 30
minutes per day, 3 or 4 days a week.  This can include
regular aerobic activities such as brisk walking, jogging,
swimming, bicycling, or playing tennis.  If you have chest
pain, feel faint or light-headed, or become extremely out of
breath while exercising, stop the activity at once and tell
your doctor as soon as possible.

If you are currently recovering from a heart attack or heart
surgery, your doctor may suggest that you begin your new
exercise program in a cardiac rehabilitation center.  A
cardiac rehabilitation center is a place that you can go to
exercise under the supervision of a nurse or doctor.


LOSE WEIGHT IF YOU ARE OVERWEIGHT

People who are overweight usually have higher blood
cholesterol levels than people of desirable weight.  When
you cut the fat in your diet, you cut down on the richest
source of calories.  An eating pattern high in starch and
fiber instead of fat is a good way to lose weight.  Many
starchy foods, such as bread, pasta, and rice, have little
fat (unless fat is added in preparation) and are lower in
calories than high-fat foods.  Check the food label to be
sure.  If you are overweight, losing even a little weight
can help to lower LDL-cholesterol and raise HDL-cholesterol. 
You don't need to reach your desirable weight to see a
change in your blood cholesterol levels.  But, as a person
who has CHD, you should really try to reduce your risk as
much as possible by getting your weight down to the
desirable level.

Two steps are key to weight loss:

*  Eat fewer calories (cutting back on the fat you eat will
   really help).

*  Burn more calories by becoming more physically active.


CHOLESTEROL-LOWERING MEDICINES

To reach an LDL-cholesterol goal of 100 mg/dL or below, you
may need to take a cholesterol-lowering medicine in addition
to making the life habit changes already mentioned.  CHD
patients need to lower their LDL more than people without
heart disease.  As a result, medications are more often used
by patients with CHD than by those who do not have CHD.  

CHD Patients and Cholesterol-Lowering Medications

CHD patients with LDL levels of 130 mg/dL or greater after
diet will generally need to take medicine.  If your LDL
level is 100 to 129 mg/dL after diet, your doctor will
consider all the facts of your case in deciding whether to
prescribe medication.  If you have been hospitalized for a
heart attack, your doctor may choose to start you on a
medication at discharge if your LDL-cholesterol is 130 mg/dL
or greater.  Also, if your LDL-cholesterol is far above the
goal level of 100 mg/dL when first measured, your doctor may
choose to start a cholesterol-lowering medication together
with diet and physical activity right from the beginning of
treatment.

If your doctor prescribes medicine, you also will need to:

*  Follow your cholesterol-lowering diet.

*  Be more physically active.

*  Lose weight if overweight.

*  Control all of your other CHD risk factors, including
   smoking, high blood pressure, and diabetes.

Taking all these steps together may lessen the amount of
medicine you need or make the medicine work better--and that
reduces your risk for a heart attack.  The following is a
description of cholesterol-lowering medicines.

Statins

There are currently four statin drugs on the market in the
United States:  lovastatin, simvastatin, pravastatin, and
fluvastatin.  The major effect of the statins is to lower
LDL-cholesterol levels, and they lower LDL-cholesterol more
than other types of drugs.  Statins inhibit an enzyme, HMG-
CoA reductase, that controls the rate of cholesterol
production in the body.  These drugs lower cholesterol by
slowing down the production of cholesterol and by increasing
the liver's ability to remove the LDL-cholesterol already in
the blood.  Statins were used to lower cholesterol levels in
both the 4S and CARE studies.  The large reductions in total
and LDL-cholesterol produced by these drugs resulted in
large reductions in heart attacks and CHD deaths.  Thanks to
their track record in these studies and their ability to
lower LDL-cholesterol, statins have become the drugs most
often prescribed when a person with CHD needs a cholesterol-
lowering medicine.

A review of 10 studies using statins reported 20 to 40
percent lower LDL-cholesterol levels in patients on this
medicine.  Statins also produce a modest increase in HDL-
cholesterol and reduce elevated triglyceride levels.

The statins are usually given in a single dose at the
evening meal or at bedtime.  It is important that these
medications be given in the evening to take advantage of the
fact that the body makes more cholesterol at night than
during the day.

You should begin to see results from the statins after
several weeks, with a maximum effect in 4 to 6 weeks.  After
about 6 to 8 weeks, your doctor can do the first check of
your LDL-cholesterol while on the medication.  A second
measurement of your LDL-cholesterol level will have to be
averaged with the first for your doctor to decide whether
your dose of medicine should be changed to help you meet
your goal.

The statins are well tolerated by most patients, and serious
side effects are rare.  A few patients will experience an
upset stomach, gas, constipation, and abdominal pain or
cramps.  These symptoms usually are mild to moderate in
severity and generally go away as your body adjusts.  Rarely
a patient will develop abnormalities in blood tests of the
liver.  Also rare is the side effect of muscle problems. 
The symptoms are muscle soreness, pain, and weakness.  If
this happens, or you have brown urine, contact your doctor
right away to get blood tests for possible muscle problems.

Bile Acid Resins

Bile acid resins bind with cholesterol-containing bile acids
in the intestines and are then eliminated in the stool.  The
major effect of bile acid resins is to lower LDL-cholesterol
by about 10 to 20 percent.  Small doses of resins can
produce useful reductions in LDL-cholesterol.  Bile acid
resins are sometimes prescribed with a statin for patients
with CHD to increase cholesterol reduction.  When these two
drugs are combined, their effects are added together to
lower LDL-cholesterol by over 40 percent.  Cholestyramine
and colestipol are the two main bile acid resins currently
available.  These two drugs are available as powders or
tablets.  They are not absorbed from the gastrointestinal
tract and 30 years of experience with the resins indicate
that their long-term use is safe.

Bile acid resin powders must be mixed with water or fruit
juice and taken once or twice (rarely three times) daily
with meals.  Tablets must be taken with large amounts of
fluids to avoid gastrointestinal symptoms.  Resin therapy
may produce a variety of symptoms including constipation,
bloating, nausea, and gas.

The bile acid resins are not prescribed as the sole medicine
to lower your cholesterol if you have high triglycerides or
a history of severe constipation.

Although resins are not absorbed, they may interfere with
the absorption of other medicines if taken at the same time. 
Other medications therefore should be taken at least 1 hour
before or 4 to 6 hours after the resin.  Talk to your doctor
about the best time to take this medicine, especially if you
take other medications.

Nicotinic Acid

Nicotinic acid or niacin, the water-soluble B vitamin,
improves all lipoproteins when given in doses well above the
vitamin requirement.  Nicotinic acid lowers total
cholesterol, LDL-cholesterol, and triglyceride levels, while
raising HDL-cholesterol levels.  There are two types of
nicotinic acid:  immediate release and timed release.  Most 
experts recommend starting with the immediate-release form;
discuss with your doctor which type is best for you. 
Nicotinic acid is inexpensive and widely accessible to
patients without a prescription but must not be used for
cholesterol lowering without the monitoring of a physician
because of the potential side effects.  (Nicotinamide,
another form of the vitamin niacin, does not lower
cholesterol levels and should not be used in the place of
nicotinic acid.)

All patients taking nicotinic acid to lower serum
cholesterol should be closely monitored by their doctor to
avoid complications from this medication.  Self-medication
with nicotinic acid should definitely be avoided because of
the possibility of missing a serious side effect if not
under a doctor's care.

Patients on nicotinic acid are usually started on low daily
doses and gradually increased to an average daily dose of
1.5 to 3 grams per day.

Nicotinic acid reduces LDL-cholesterol levels by 10 to 20
percent, reduces triglycerides by 20 to 50 percent, and
raises HDL-cholesterol by 15 to 35 percent.

A common and troublesome side effect of nicotinic acid is
flushing or hot flashes, which are the result of the
widening of blood vessels.  Most patients develop a
tolerance to flushing, and in some patients, it can be
decreased by taking the drug during or after meals or by the
use of aspirin or other similar medications prescribed by
your doctor.  The effect of high blood pressure medicines
may also be increased while you are on niacin.  If you are
taking high blood pressure medication, it is important to
set up a blood pressure monitoring system while you are
getting used to your new niacin regimen.

A variety of gastrointestinal symptoms including nausea,
indigestion, gas, vomiting, diarrhea, and the activation of
peptic ulcers have been seen with the use of nicotinic acid. 
Three other major adverse effects include liver problems,
gout, and high blood sugar.  Risk of the latter three
increases as the dose of nicotinic acid is increased.  Your
doctor will probably not prescribe this medicine for you if
you have diabetes, because of the effect on your blood
sugar.

Other Drugs

Fibrates

The cholesterol-lowering drugs called fibrates are primarily
effective in lowering triglycerides and, to a lesser extent,
in increasing HDL-cholesterol levels. Gemfibrozil, the
fibrate most widely used in the United States, can be very
effective for patients with high triglyceride levels. 
However, it is not very effective for lowering LDL-
cholesterol.  As a result, it is used less often than other
drugs in patients with CHD for whom LDL-cholesterol lowering
is the main goal of treatment.  Gemfibrozil therapy by
itself is not recommended by the Food and Drug
Administration for patients with CHD.

Fibrates are usually given in two daily doses 30 minutes
before the morning and evening meals.  The reductions in
triglycerides generally are in the range of 20 to 50 percent
with increases in HDL-cholesterol of 10 to 15 percent.

Fibrates are generally well tolerated by most patients. 
Gastrointestinal complaints are the most common side effect
and fibrates appear to increase the likelihood of developing
cholesterol gallstones.  Fibrates can increase the effect of
medications that thin the blood, and this should be
monitored closely by your physician.

Hormone Replacement Therapy

The risk of CHD is increased in postmenopausal women,
whether the menopause is natural, surgical, or premature. 
This increasing risk may be related to the loss of estrogens
after menopause.  Hormone replacement therapy (HRT) is
treatment with estrogen, either alone or with another
hormone called progestin.  HRT may be prescribed when women
experience symptoms from menopause.

HRT can be given in many different forms and amounts.  Your
doctor will help you select the best form for you.

A recent study called the Postmenopausal Estrogen/Progestin
Interventions (PEPI) Trial looked at whether estrogen acts
on some of the factors that define a woman's risk of heart
disease.  Results from the PEPI study showed that:

*  Estrogen-only therapy raises the level of HDL-
   cholesterol.

*  Combined estrogen-progestin therapies also increased HDL
   levels, although less than estrogen alone.

*  All of the hormone regimens decreased the level of LDL-
   cholesterol about equally well.

*  None of the hormone regimens caused a significant weight
   gain.

*  All of the hormone regimens caused a rise in triglyceride
   levels.

In postmenopausal women with CHD, HRT can play a role in
improving LDL- and HDL-cholesterol levels.

Combination Drug Therapy

If your goal LDL level is not reached after 3 months with a
single drug, your doctor may consider starting a second
medicine to go with it.  Combination therapy can increase
your cholesterol lowering, reversing or slowing the advance
of atherosclerosis and further decreasing the chance of a
heart attack or death.  The use of low doses of each
medicine may help reduce the side effects of the drugs.


OTHER MEDICATIONS COMMONLY PRESCRIBED FOR CHD

In addition to cholesterol lowering and control of the other
risk factors, there are other treatments to help lower your
risk from CHD.  Aspirin, a drug that has been used for
centuries to relieve pain and reduce fever, has been shown
to reduce the risk of future heart attacks in patients who
have already had one.  Aspirin seems to work by reducing the
stickiness of the platelets (the cells that cause blood
clotting) so that blood clots do not form as readily.  After
bypass surgery, patients treated with aspirin have fewer
early closures of the newly grafted blood vessels in their
hearts.

Beta-blockers, another type of drug, have been shown to
reduce death rates in patients who have CHD.  Beta-blockers
slow the heart and make it beat with less contracting
force--so blood pressure drops and the heart works less
hard.

Many patients with CHD have high blood pressure.  Other
drugs in addition to beta-blockers may be needed to reach a
normal blood pressure.

The amount of risk reduction shown by aspirin and beta-
blockers is similar to that of cholesterol lowering, making
all three important in the treatment of heart disease.


NEXT STEPS

Talk to Your Doctor--Be Part of Your Health Care Team

There are two key people in your health care team, you and
your doctor.  You are just as important as your doctor in
directing your health care.  Only you know how you feel,
what you are doing or not doing to improve your health, what
you expect from your health, and any difficulties you may be
having.  It is important for you to tell your doctor these
things so he or she can recommend the best treatment.

The first step you should take in becoming an active member
of your health care team is to understand what you are being
treated for and why.  Continue to ask questions until you
understand the answer.

It is important for you to understand your coronary heart
disease, the special diet you are on, medicines you may be
taking, and the tests needed to follow your progress.  Ask
about the benefits of medications as well as possible side
effects.  If you are aware of possible side effects of a
treatment, you will be able to manage them better.  (See
suggestions for remembering your medicine on page 30.)

By paying attention to your health and maintaining your own
records, you will become an active decision maker in your
health care.  (See cholesterol-monitoring log on page 31.)

Get Support

In addition to your doctor, other health professionals can
help you control your blood cholesterol levels.  These
persons include:

*  Registered nurses (RNs) can explain your treatment plan
   to you, show you how to take your medication, and help
   you find other sources of information and help.  As the
   health care provider you see the most, nurses are a key
   resource when you are lowering your cholesterol.

*  Registered dietitians (RDs) or qualified nutritionists
   can explain food plans, show you how to make changes in
   what you eat, and give you advice on shopping for and
   preparing foods and eating out.  They also can help you
   set goals for changing the way you eat, so you can
   successfully lower your high blood cholesterol without
   making big changes all at once in your eating habits or
   in your lifestyle.  Information on how to find a
   dietitian in your area can be found on page 33.

*  Lipid specialists are doctors who are experts in treating
   high blood cholesterol and similar conditions.  You may
   be referred to a lipid specialist if the treatment your
   doctor is prescribing does not successfully lower your
   blood cholesterol levels.

*  Pharmacists are aware of the best ways to take medicines
   to lessen side effects and of the latest research on
   drugs.  They can help you stay on your drug treatment
   program.

Many people need help while making changes in life habits to
reduce their risk; do not be afraid to ask for help from
family, friends, and your health care team.  Involve your
spouse, family members, or significant others in your
treatment plan.  By sharing your problem and the importance
of cholesterol-lowering goals (LDL of 100 mg/dL or less),
your current treatment plan, and your medication schedule,
you can get the help you need to succeed in controlling your
cholesterol and lowering your risk.

Long-Term Monitoring

Because you have CHD you will need to monitor your
cholesterol and other risk factors for the rest of your
life.  By discussing your monitoring plan with your health
care provider, both you and your physician will be more
likely to stick to this plan.  Several helpful hints are
provided in the box below to help you avoid relapsing to a
less healthy lifestyle.  If you have a specific problem that
is not listed here, discuss it with your doctor, nurse, or
dietitian.

Helpful Hints To Monitor Your New Lifestyle

1.  Record your test results at each visit.

2.  Set realistic short-term goals and write them down.

3.  Review your goals during each visit with your health
    care provider.

4.  Share your goals with your family and friends.  Support
    is often the key to success.

5.  If you find yourself unable to keep to your plan, write
    down all of the reasons that you think are responsible.
    Next, write down what alternatives you have if that
    situation happens again.  If you prepare an alternate
    strategy in advance, you are more likely to stick to
    your plan and reach your goals.

When setting your goals with your health care provider,
remember the target cholesterol level for persons with CHD:  

                LDL-cholesterol:  100 mg/dL or lower

In addition, since a low HDL-cholesterol level increases CHD
risk, patients with CHD should aim to have an HDL-
cholesterol higher than 35 mg/dL.

Maintaining Healthy Behaviors and Overcoming Relapse

Question:    My last cholesterol level was within my goal. 
             Does that mean I do not have to worry about my
             cholesterol any more?

Answer:      High cholesterol and heart disease are not
             cured but are only controlled by diet and drug
             therapy.  Stopping your treatment quickly
             returns your cholesterol to the level that
             existed before therapy was started.

The goal of diet, physical activity, weight loss, and
medicine is to keep your blood cholesterol under control.  A
slowing in the progression or a regression of
atherosclerotic plaque in your coronary arteries is likely
to be seen after 1 to 2 years of intensive cholesterol
lowering.  These observations support the need to continue
cholesterol-lowering therapy for years.  It seems that
maximum benefit is achieved only if therapy is sustained for
the rest of your life.

Many people find lifelong changes in diet and activity
difficult to manage.  It is important to remember that
because you may not always stick with your new diet or
exercise plan, you are not a failure--just human.  The most
important part of your new healthy lifestyle is learning how
to overcome these challenges and quickly return to your
goal.

Eat Right at Social Events

Eating at social events like parties, receptions, family
gatherings, and church socials can be a challenge to your
heart-healthy eating style.  Since you can't control what is
served, you may feel pressured to eat foods high in
saturated fat and cholesterol.

Here are some tips that will help you eat healthfully at
social events:

*  At a buffet, look ahead in line to see what low-fat foods
   are available.  Fill up on low-fat items and take only
   small servings of high-fat foods.

*  Bring a low-fat dish to a potluck dinner.  That way,
   you'll have at least one low-fat item from which to
   choose.

*  At parties, focus on activities other than eating.  Sit
   away from the area where the food is being served so you
   won't be tempted to overeat.

*  Ask for help from your family and friends who know you
   are following a cholesterol-lowering diet.  See if they
   will include some low-fat dishes on the menu.

*  Have a few ready answers to politely say no to high-fat
   foods.  For example, "Thank you, but I couldn't eat
   another bite--everything was delicious."

*  If you do eat too many high-fat foods at a social event,
   don't feel guilty.  Just eat lightly the next day and get
   back on track.

Eating Out

Are you a smart customer when eating out?  You will be if
you follow these tips:

*  Choose restaurants that have low-fat, low-cholesterol
   menu choices.  And don't be afraid to make special
   requests--it's your right as a paying customer.

*  Control serving sizes by asking for a small serving,
   sharing a dish with a companion, or taking some home.

*  Ask that gravy, butter, rich sauces, and salad dressing
   be served on the side.  That way, you can control the
   amount you eat.

*  Ask to substitute a salad or baked potato for chips,
   fries, or other extras--or just ask that the extras be
   left off your plate.

*  When ordering pizza, order vegetable toppings like green
   pepper, onions, and mushrooms instead of meat toppings or
   extra cheese.  To make your pizza even lower in fat and
   saturated fat, order it with half the cheese or no
   cheese.

*  At fast-food restaurants, go for salads, grilled (not
   fried or breaded) chicken sandwiches, regular-sized
   hamburgers, or roast beef sandwiches.  Go easy on the
   regular salad dressings and fatty sauces.  Limit jumbo or
   deluxe burgers or sandwiches. 

How To Stay on Your Cholesterol-Lowering Medication

The first step to staying on your medication is
understanding what you are taking and why.

*  Ask your doctor what you are being treated for and how
   each medicine helps.

   For example:  If you are taking a statin, you should know
   that is for lowering your LDL-cholesterol to lower your
   heart disease risk.

*  Know the side effects of any medications you are taking. 
   You can find this out by asking your doctor or
   pharmacist.

*  Ask your doctor how your medicine works with your other
   medications and the foods you eat.

   For example:  Some medicines work best if you take them
   with food, and others work best if you take them at
   bedtime.

*  Ask your doctor what to do if you miss a dose of medicine
   or have problems with side effects.  It is important that
   you keep your doctor informed of how the medicine is
   working for you.  It may be useful to ask your doctor for
   help in completing a chart on all of your medicines that
   includes the name of the medication, what the medication
   is being taken for, when to take it, what side effects to
   watch for, and whom to call if you should have a problem.

Remembering to take your medicine is important.  Daily
reminders are often helpful when scheduling your medication
doses.  Try to time taking your medicine around activities
that you do daily such as setting your alarm clock, brushing
your teeth, eating your meals, going to work, or doing other
daily activities.

Other ways to help yourself remember to take your medicine
could be:

*  Setting your watch alarm to go off when it's time to take
   your medicine

*  Placing a reminder card in a visible place

*  Having a family member or a friend remind you

*  Use a medication box that will hold your entire day's
   supply of medicine.  This will let you know if you missed
   a dose of medicine. 

If you have tried these tricks and still have trouble
remembering your medicine, talk to your doctor or
pharmacist.  It may be possible to simplify your medication
schedule or to put your medicine in special containers
called blister packs to help you.

Cholesterol-Monitoring Log

Date

Medication Name

Dose

LDL-Cholesterol

Total Cholesterol

HDL-Cholesterol

Triglycerides


QUESTIONS YOU MAY BE WONDERING ABOUT

Do I need to worry about lowering my blood cholesterol now
that I'm over 70?

A recent study (4S) showed that cholesterol lowering in
older patients with CHD significantly reduced the risk for
heart attacks and deaths from CHD and prolonged the lives of
study participants, just as it did in middle-aged patients. 
Older Americans who have CHD should lower their LDL-
cholesterol levels to reduce the risk of having a future
heart attack.  They should also reduce other cardiovascular
risk factors by not smoking and controlling high blood
pressure.

Should I be concerned about my child's blood cholesterol?

Children from families in which a parent or grandparent has
developed heart disease at an early age (before age 55 in
father or grandfather, or before age 65 in mother or
grandmother) should have their cholesterol levels tested. 
If a child from such a "high-risk" family has a cholesterol
level that is high, it should be lowered under medical
supervision, primarily with diet.  By following a low-
saturated fat and low-cholesterol eating pattern, by being
physically active, and by avoiding obesity, even healthy
children can lower their risk of developing heart disease as
adults.

How useful is it to know my cholesterol ratio?

Although the cholesterol ratio can be a useful predictor of
heart disease risk, especially in the elderly, it is more
important for treatment purposes to know the value for each
level separately because both LDL- and HDL-cholesterol
separately affect your risk of heart disease and the levels
of both may need to be improved by treatment.  If you have
LDL-cholesterol above 100 mg/dL, lowering your LDL-
cholesterol is the main goal of treatment.  Your doctor
will, however, also consider your HDL when deciding on
treatments and goals.  The ratio is useful if it helps you
and your doctor keep the entire picture of your LDL and HDL
levels in mind, but it should not take the place of knowing 
your separate LDL and HDL levels.

What if I need heart surgery?

Bypass surgery or balloon angioplasty will improve the blood
supply to the heart, but it does not mean you can ignore
your cholesterol level or the other CHD risk factors.  Even 
though surgery restores blood flow in the heart, poor life
habits will clog your new arteries even faster than they
clogged your old ones.  So pay attention to your risk
factors especially after surgery.  Trying to lower LDL-
cholesterol to about 100 mg/dL or less is an important goal
for CHD patients.  Many patients who have bypass surgery or
balloon angioplasty have not actually had a heart attack. 
Cholesterol-lowering treatment in these patients is very
important to lessen the chances of a future heart attack.

What if I have the warning signs of a heart attack?

If you have coronary heart disease, you should know the
symptoms of a heart attack so that you can get immediate
medical help.  The most common symptoms are:

*  Uncomfortable pressure, fullness, squeezing or pain in
   the center of the chest that lasts more than a few
   minutes, or goes away and comes back.

*  Pain that spreads from the chest to the shoulders, jaw,
   or arms.

*  Chest discomfort with lightheadedness, fainting,
   sweating, nausea, or shortness of breath.

These symptoms may be severe from the start, or they may be
mild at first, then gradually worsen.  In some people, the
warning symptoms come and go.

If you experience any symptoms of a heart attack, get
medical help immediately.  Be sure you know the phone number
so you can get emergency transportation to the hospital.  If
you are having a heart attack, getting to the hospital fast
is very important.  Medical treatment, including clot-
dissolving medicine, can save lives and reduce damage to the
heart muscle, but only if it is started very soon after a
heart attack occurs.

Talk with your doctor about the symptoms of a heart attack
and what to do if you experience them.


GET MORE INFORMATION

The National Cholesterol Education Program (NCEP),
coordinated by the National Heart, Lung, and Blood Institute
(NHLBI), has a pamphlet called Step by Step:  Eating To
Lower Your High Blood Cholesterol.  This pamphlet gives
details on how to change your eating habits in order to
lower your blood cholesterol levels.  The NCEP also has
booklets for children with high blood cholesterol levels and
their parents.  In addition, the NHLBI has a booklet,
Exercise and Your Heart:  A Guide to Physical Activity.  To 
receive these publications please see the Government
Printing Office (GPO) order form on page 34.  The NHLBI can
also provide you with the names of additional agencies and
organizations able to answer questions on cholesterol and
the other risk factors for heart disease.  To obtain this
information please write to:

      NHLBI Information Center
      P.O. Box 30105
      Bethesda, MD  20824-0105

The American Heart Association can also provide you with
additional information.  Contact your local American Heart
Association or call 1-800-AHA-USA1 (1-800-242-8721).

To find a registered dietitian contact:

  The National Center for Nutrition and Dietetics' Consumer
  Nutrition Hotline 1-800-366-1655

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Superintendent of Documents Publications Order Form
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Discrimination Prohibited: Under provisions of applicable
public laws enacted by Congress since 1964, no person in the
United States shall, on the grounds of race, color, national
origin, handicap, or age, be excluded from participation in,
be denied the benefits of, or be subjected to discrimination
under any program or activity (or, on the basis of sex, with
respect to any education program or activity) receiving
Federal financial assistance. In addition, Executive Order
11141 prohibits discrimination on the basis of age by
contractors and subcontractors in the performance of Federal
contracts, and Executive Order 11246 states that no
federally funded contractor may discriminate against any
employee or applicant for employment because of race, color,
religion, sex, or national origin. Therefore, the National
Heart, Lung, and Blood Institute must be operated in
compliance with these laws and Executive Orders.

U.S. Department of Health and Human Services
Public Health Service
National Institutes of Health
National Heart, Lung, and Blood Institute

NIH Publication No. 96-3805
September 1996