Low-density lipoprotein often is referred to as bad cholesterol because it carries cholesterol into the blood, where it can do harm. LDL plays the lead role in causing fatty buildup in the arteries, increasing the risk of heart disease.

High-density lipoprotein, the good cholesterol, carries blood cholesterol back to the liver where it can be disposed of. HDL also aids in producing hormones, building cell walls and digesting dietary fats.

High LDL levels greatly increase risk while normal HDL levels can decrease risk. This is where statins have come into play in a big way, but not just because of their direct impact on cholesterol levels.

Although some have tried to claim that statins should not be used by anyone other than those with a high risk of heart disease, the evidence of early intervention is compelling. Large-scale intervention trials have shown a clear relationship between reduction of cholesterol and reduction in mortality. This kind of data has driven guideline bodies to recommend more aggressive treatment.

Data has shown that a 1% decrease in LDL cholesterol reduces heart disease risk by 1%. In addition, epidemiology studies have shown that HDL-cholesterol levels can influence cardiovascular risk alongside LDL-cholesterol levels; a 1% change in HDL has been shown to be associated with a 1% to 3% reduction in heart-disease risk.

Lipid-management guideline treatment goals have become more aggressive and are likely to become even more so with the availability of more effective therapies. The evidence has driven this evolution, which also has been seen in other national and international guidelines, from the statin trials (together with epidemiological evidence) that confirm that effective lowering of LDL is the key driver for reducing cardiovascular events. Achieving the goals set out in evidence-based guidelines is therefore important in saving lives and reducing cardiovascular events.

The remaining question is at what point should doctors begin statin therapy and which statin to use for which purpose? Here too, a one-size fits all approach should be avoided. For instance, studies have found that certain drugs such as rosuvastatin seem to be better metabolized by people of Asian and Latin American origin than Caucasians. Variations in response also occur in patients by age, weight, smoking habits and sex, though all of these are likely to be representative of individual genetic variations that have yet to be clearly identified.

Finally, recent studies and new markers for heart attacks such as the C-reactive protein test show that the relative benefit of statins to be greater among those with increased CRP and that achieved CRP levels after statin therapy and that an increase in CRP levels predict reduced rates of heart attacks as much as achieved levels of LDL cholesterol.

The best approach to reducing cardiovascular disease among firefighters is a personalized and prospective one. Departments, in cooperation with health plans, university medical centers and other health providers, should create personalized strategic health plans for each member of their force:

1. Develop a one-page form that collects all necessary personal clinical data that have predictive power for cardiovascular diseases and metabolic diseases. Using published research, develop a computer-based algorithm that uses the historical, demographic and clinical data to make specific health protective recommendations (diagnostic, lifestyle or therapeutic) for each person.

2. Assign each department a health advocate to help implement the strategy for every firefighter.

3. Provide each firefighter who completes an annual health report form a cash bonus that could be increased based on how healthy he or she is.

The NFPA and CDC could collect the data and conduct evaluations on changes in health measures. And while the payment to stay healthy may seem out of the ordinary, consider that firefighters are paid to save others. It would be both cost-effective and appropriate to invest a small amount of money to reward them if they took steps to help save themselves.

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Michael Weber, M.D., is associate dean and professor of medicine at the State University of New York Health Science Center at Brooklyn. He also is a fellow of the Council for High Blood Pressure Research of the American Heart Association, the American College of Cardiology, and the American College of Clinical Pharmacology. Weber currently serves as a consultant to the Center for Drug Evaluation and Research of the FDA.