March 21, 2014
News Review From Harvard Medical School -- Guidelines Would Boost Statin Use by 13 Million
Under new guidelines, statin drugs could be recommended for up to half of U.S. adults between 40 and 75. That's an increase of nearly 13 million Americans. The estimate comes from a new study. It focuses on the effect of new guidelines for reducing LDL ("bad cholesterol"). The American Heart Association and the American College of Cardiology published them last fall. The new group eligible for statins includes adults ages 40 to 75 who have a 7.5% risk of developing heart disease in the next 10 years. Researchers looked at medical records for 3,700 people. They found that statin use would increase most for those 60 to 75. Under the old guidelines, about 30% of men in this group who did not have heart disease were eligible to take statins. The new guidelines would boost that to 87%. Statins would be recommended for 53% of women ages 60 to 75 without heart disease. That's up from 21%. Recommended use in healthy, younger adults (40 to 59) would increase only slightly, from 27% to 30%. About 1.6 million younger adults would no longer be eligible for statins. The New England Journal of Medicine published the study March 20. HealthDay News wrote about it.
By Mary Pickett, M.D.
Harvard Medical School
What Is the Doctor's Reaction?
If you are a man who is older (say, age 60-75), even if you don't have heart disease, you should be taking a statin.
I can make that statement and I will be right almost 9 times out of 10, according to a new analysis. This study looked at new cholesterol guidelines that were released in November by the American Heart Association (AHA) and American College of Cardiology (ACC). The analysis applied the guidelines to a group of typical Americans. The goal was to see whether a statin drug would be recommended to prevent heart disease and stroke.
Information about 3,773 Americans came from National Health and Nutrition Examination Surveys. Researchers first determined whether a statin would be recommended for each person based on old cholesterol guidelines. They were used from 2004 until this year. Then they applied the new guidelines.
They found that the new guidelines would increase the number of Americans eligible for statin drug therapy by almost 13 million. Almost all of the increase was among adults who did not have heart disease, but were at risk to develop it.
- Among men ages 60-75 who are not already on a statin, and who have no heart disease, 87.4% are now eligible to take a statin.
- Among women age 60-75 who are not already on statin, and who have no heart disease, 53.6% are now eligible to take a statin.
- Among men and women age 40-59, 29.7% are now eligible to take a statin.
If patients go along with the guidelines, all of these added statins may prevent as many as 475,000 heart attacks and stroke (fatal and non-fatal) over 10 years. But is this enough to convince Americans to start a statin? Not in my experience.
I am a primary care doctor. I have been talking with my patients about these new guidelines. I am offering statins to almost all of my patients who are eligible. But so far, most of my patients are not ready to make this change.
"No thanks, Doc."
"Maybe in a year or two."
My patients want to reduce their heart attack and stroke risk. They are willing to plan exercise, to take aspirin, to talk about diet changes. But taking a statin drug sounds too commercial for some. For others, it is too costly or too risky.
When doctors decide that all Americans should get a vaccine to prevent disease, this seems reasonable. But when doctors decide so many Americans should take a daily drug, it feels different. I don't think my patients are being unreasonable to have doubts about the guideline. This guideline is an aggressive way to prevent heart disease. It won't feel right for everyone.
What Changes Can I Make Now?
Statins are an opportunity. But then again, life is full of opportunities. Some have trade-offs involved. In this case, statins can prevent heart disease, but they do have potential side effects and they do cost money. For some people, statins do not seem "natural" enough to be an appealing way to prevent disease.
If you are interested, talk to your doctor about the new cholesterol guidelines.
Previously, doctors used statins to lower LDL (sometimes called "bad cholesterol") to a target number. But the new guidelines change that. Unless your LDL is extremely low (less than 70), guidelines now advise doctors to recommend statins for anyone in these groups:
- People with a history of atherosclerosis (coronary artery disease, stroke or other artery disease)
- People ages 40-75 who have diabetes
- People with very high LDL cholesterol (at or above 190 milligrams per deciliter (mg/dL)
- People who have a 10-year risk of heart attack OR stroke that is more than 7.5% without a statin. The AHA and ACC have developed a risk calculator that is available online. The calculator takes into account your age, race, smoking history, cholesterol levels and whether or not you have diabetes or high blood pressure.
The new guidelines also recommend that most people take a high dose of a statin drug, Exceptions would be people who:
- Are over age 75
- Have liver, kidney or muscle disease
- Have side effects from statins
- Have a relatively small calculated risk for heart attack and stroke
Examples of high doses are atorvastatin (Lipitor) 40 to 80 milligrams, or rosuvastatin (Crestor) 20 to 40 milligrams.
What Can I Expect Looking to the Future?
Doctors are still adjusting to the new guidelines. Some experts think that the calculator is not accurate. They say it may overestimate the risk for heart attack and stroke. Some experts think it is better to start statins at a low dose. And some are asking, should the amount of time a person stays on a statin be limited to a fixed number of years, or is there an older age at which we should stop these drugs? These questions will be debated during the next several years.