November 13, 2013
News Review From Harvard Medical School -- New Guidelines May Double Use of Statins
Heart disease experts have released new advice that could almost double the use of statin drugs in preventing and treating heart disease. The changes are among four new sets of guidelines from American Heart Association and the American College of Cardiology. Both groups published them in journals November 12. The guidelines on cholesterol contain the biggest changes. Statin drugs reduce LDL ("bad cholesterol") and inflammation. They have been shown to help prevent heart disease, heart attack and stroke. Doctors use them to lower LDL to a target number. The new guidelines drop the targets. Instead, they say doctors should assess people's overall risk of heart disease or stroke. The changes could increase the number of Americans taking statins from 36 million to 70 million. Doctors would still prescribe statins for those with heart disease or very high LDL and middle-aged adults with type 2 diabetes. Other adults, ages 40 to 75, would get statins based on overall risk using a new calculator. The trigger for treatment would be a heart disease or stroke risk of 7.5% in the next 10 years. Adding stroke risk is one factor that could expand statin use. HealthDay News and many other news media wrote about the guidelines.
By Reena L. Pande, M.D.
Harvard Medical School
What Is the Doctor's Reaction?
The American Heart Association and the American College of Cardiology just released new guidelines on prevention and reducing heart disease risk. The four topics are:
- Assessment of a person's risk of heart attack or stroke
- Treatment of cholesterol to reduce risk of atherosclerosis (plaque buildup in arteries)
- Lifestyle management to reduce risk of heart and artery disease
- Management of overweight and obesity in adults
The overall lessons are the same as the ones we've long been hearing:
- Eat right
- Maintain a healthy weight
- Control your blood pressure and cholesterol
So what's new? Let's focus on one major change worth highlighting.
The new cholesterol guidelines may double the number of people eligible for treatment with statin drugs.
Statins are a group of medicines that lower cholesterol and reduce the risk of heart and artery disease. The new guidelines recommend that patients in any of the following groups be treated with a statin:
- People who have heart and artery (cardiovascular) disease
- People with very high levels of LDL, sometimes called "bad cholesterol." An example would be an LDL of greater than 190 milligrams per deciliter (mg/dL).
- Anyone between the ages of 40 and 75 who has type 2 diabetes
- People who have a high risk of developing heart disease in the next 10 years. There are tools people can use to get a better sense of their own risk of heart disease.
These guidelines sound reasonable. So how are they different?
The prior guidelines told doctors to use statin treatment to reach specific goals or targets. For example, in a patient with heart disease, the prior goal was to get the LDL down to 100 mg/dL. The goal could be as low as 70 mg/dL in people with heart problems who were at particularly high risk.
The new guidelines take away this "target-driven" approach. Instead, they tell us to base our treatment decisions on risk. So anyone at high enough risk who stands to benefit from a statin should be taking one. It doesn't matter so much what a person's actual cholesterol level was when we started treatment.
There are a few reasons for these new risk-focused guidelines.
- Statins in the right doses do a great job of lowering cholesterol.
- Statins also have other benefits. We have long known that statins lower the risk of death, heart attack and stroke, even for people with relatively normal cholesterol levels. And we certainly know that people with normal cholesterol can have heart attacks.
Having patients on the right doses of statins may be more important than reaching a particular target number. In many cases, the right doses are those that clinical trials have shown provide a benefit.
What Changes Can I Make Now?
So will these guidelines change clinical practice? Yes and no. Many doctors already are focusing on balancing risk and benefit when they make decisions about treatment. I, for one, am already prescribing statins to people who have a high risk of heart disease even if their cholesterol is close to normal. But what will be new is making sure patients are on an effective dose and no longer focusing on the number targets.
So what can you do?
- Go beyond the numbers. We have long been focused on cholesterol numbers. But these new guidelines take you beyond the numbers. Instead, talk with your doctor about your risk of heart disease. This may well be a better guide to whether you should be taking a statin or not.
- Consider the risks. Of course, no treatment is without some risk. Statins can cause muscle cramps. In a small number of people, they can cause more significant muscle injury and liver problems. They have also been linked with a higher risk of diabetes and memory issues, although this risk appears to be very small. In the end, it's a matter of balancing the risk of side effects with the potential benefit of reducing the risks of heart disease, stroke and death. Have an open conversation with your doctor to consider your personal risks and benefits.
- Remember the other stuff. These new guidelines are also quick to remind us that there is more to lowering risk than just prescribing statins. As doctors and as patients, we need to remain focused on healthy living. This means eating right, getting exercise, not smoking and maintaining a healthy weight.
What Can I Expect Looking to the Future?
I think that we are entering a new era of heart disease prevention. We will move toward a risk-driven approach instead of a target-driven approach.
The new guidelines remind us that it's not all about the numbers. It's about treating:
- The right patient (high enough risk)
- With the right statin (the ones used in the clinical trials)
- At the right dose (those that have been proven to lower heart risk)
That is the central goal, no matter what the person's baseline or target cholesterol levels may be. It's a shift in thinking, but it's a shift in the right direction.