When the American Heart Association and the American College of Cardiology released a new set of guidelines for pharmaceutical management of blood cholesterol in mid-November, many people — physicians and patients alike — were surprised.
According to estimates by the authors, the new guidelines could double the number of people prescribed statins, from the current 15.5 percent to 31 percent of adults. “Statins have significant benefits, but those benefits may only apply to certain patients,” says Matthew Lucks, MD, a Scripps Health cardiologist.
The revised guidelines represent a significant change in how physicians and patients approach the question of whether to include statins in cardiac risk management. Based on a four-year review of the best available research studies and evidence, the guidelines are not focused solely on cholesterol levels; instead, they were designed to lower the overall number of heart attacks and strokes.
“I understand where the researchers are coming from,” says Dr. Lucks. “They’re tapping the latest data from clinical trials to fine-tune our knowledge of stroke and heart disease.”
He emphasizes that the new guidelines should prompt a discussion between physicians and patients, but shouldn’t necessarily lead to a rush of new prescriptions.
“My advice to patients would be to stay on their current course of treatment, and then do a measured evaluation after their physician has carefully surveyed all the new data and guidelines. Each patient should have an individualized discussion about his/her specific health situation,” he says.
Previously, physicians prescribed statins to bring LDL cholesterol down into a target zone of 70 – 100. But surprisingly, the committee that created the new standards examined all the available evidence and concluded there is no convincing evidence that specific cholesterol targets lower the incidence of heart attack or stroke.
Instead of focusing on cholesterol numbers, the new guidelines encourage physicians and patients to determine whether a particular person is at broader risk of cardiovascular problems.
According to the new guidelines, statins should be considered for people:
- Who have already been diagnosed with heart disease
- Whose “bad” cholesterol (low-density lipoprotein, or LDL) values are higher than 190 milligrams per deciliter, often due to genetics
- Are middle-aged and have been diagnosed with Type 2 diabetes
- Are between the ages of 40 and 75 with more than a 7.5 percent 10-year risk of heart disease, as determined by a calculator that measures known risks like race, age, gender and smoking
Beyond those groups, however, there’s more ambiguity. “The new guidelines don’t address some patient populations who might benefit from statins, such as those with lupus or rheumatoid arthritis,” says Dr. Lucks. In addition, some early critics suggest the new calculator could be overstating risk by as much as 100 percent, which could result in overtreatment. The committee that drafted the guidelines is currently reviewing its data to address these objections.
Genetics may also complicate matters. Today, genetic testing can pinpoint individuals with genes that can interfere with the action of statins, making them less likely to respond to treatment. Others are genetically predisposed to rare negative side effects of statins, including neurological and muscle problems.
“If we begin statin therapy, we want to use the lowest effective dose to minimize the risk of side effects and keep monitoring the patient’s condition over time,” Dr. Lucks says. But the primary ways heart attack and stroke risk can be minimized are still lifestyle related: managing high blood pressure (hypertension), tobacco cessation, a healthy diet, plenty of exercise and physical activity.
In the end, the new statin guidelines could help patients and physicians alike by focusing their conversations and actions on disease prevention and management, rather than abstract blood cholesterol numbers. “You can’t rely solely on a pill to do magic, but sometimes a pill in combination with lifestyle adjustments can create the best treatment,” says Dr. Lucks.