She is a 39-year-old woman who had a heart attack on the same day that the AAP issued these controversial guidelines. This caused so much damage to her heart that her body is connected to a device called an intraaortic balloon pump that helps her heart deliver blood to her body. Without this device, blood flow to her brain would drop so drastically that she would die. Eventually she will require some sort of surgery--perhaps bypass surgery or implantation of a permanent heart-assist pump--in order to leave the hospital. For now she's unable to get out of bed.

Susan obviously wishes that she never had this heart attack, and feels puzzled about Jack's comment. She understands that she did not lead a perfect lifestyle, but she did not lead a particularly bad one, either. Mostly she wishes that she did not suffer from such a bad case of her underlying disease--coronary atherosclerosis--and wishes that it had not become so severe that it caused a heart attack. She agrees that we should do things that are likely to protect protect the hearts of today's kids, including (but certainly not limited to):

1) Healthier lifestyle, including exercising more and eating healthier foods, and
2) Cholesterol medication to try to prevent coronary atherosclerosis, possibly starting at the young age when atherosclerotic plaque begins to form

Jack, I agree with you about the importance of a healthy lifestyle. However, I'm not sure why you oppose number two. If Susan had started taking cholesterol medications when she was 8 years old, and if that had prevented her heart attack, would you change your mind? Would you insist that she suffer the heart attack that's making her lie in bed with this pump in her chest? After all, the problem is atherosclerosis, which has many causes, including, but not limited to, an unhealthy lifestyle.

I imagine that Jack might respond, "a better lifestyle alone might have been adequate to save her." True--sometimes this strategy will succeed. But sometimes it will fail. Avid runner Jim Fixx demonstrated this--despite leading an extraordinarily healthy lifestyle, he died of a heart attack at age 52. Would he still be alive if he had received cholesterol drugs as a kid?

It's not certain that cholesterol medicines would have saved Fixx, or Susan, or any other individual. However, we have lots of evidence about what happens when carefully selected people at high risk for heart attack take cholesterol medication: On average, they live longer, healthier lives. Some people have side effects, but repeated studies have demonstrated that the benefits outweigh the risks in the right population.

Some experts agree with Jack's statement. Dr. David Ludwig, director of the childhood obesity program at Children's Hospital in Boston, commented on the AAP recommendation:

"My concern is what this is saying about society when we are so quick to prescribe drugs for these conditions before having systematically attacked the problem from the public health perspective."

Dr. Ludwig, what it's saying is that our society cares so much about people like Susan that we're willing to take an aggressive approach to prevent heart attacks. When will you declare that society has "systematically attacked the problem from a public health perspective?" Until that time, should we refuse to offer new preventive treatments to people at high risk of a heart attack? How many people should suffer preventable heart attacks while you work through your concern about what kind of society you want to live in?

To those who work at the AAP: We don't know how many people will have to take cholesterol medication in this new strategy in order to save one life. I disagree with your recommendations on the technical grounds, summarized in this thoughtful critique. However, Susan and I hope that you will ignore the insults coming your way. You're trying to save lives, and, even though I disagree with you on the details, I applaud your efforts.