November 19, 2013
News Review From Harvard Medical School -- New Statin Guidelines Questioned
Last week, heart disease experts released new advice that could almost double the use of statin drugs. These cholesterol-lowering drugs help prevent heart disease, heart attack and stroke. The new guidelines say doctors should prescribe statins based on a person's overall risk of heart disease or stroke, not to reach a specific LDL ("bad cholesterol") target number. A new online risk calculator was introduced to help doctors determine a patient's risk. Two doctors from Harvard Medical School say that the new risk calculator exaggerates a person's risk of heart disease or stroke. This could result in doctors recommending cholesterol-lowering drugs to millions of people who may not need them. The doctors tested the calculator on their own using newer data than was used to make the calculator. The New York Times reported on the dispute. HealthDay News wrote about it November 18.
By Howard LeWine, M.D.
Harvard Medical School
What Is the Doctor's Reaction?
Statins are great drugs. Yes, they lower cholesterol. And that's important. But they do much more. Lots of other drugs lower cholesterol levels. Not as much as statins do. These others might be strong enough if the only goal was just a better cholesterol number on a lab report.
Statins lower the risk of developing hardening of the arteries. And they help prevent heart attack and stroke. That's what matters! Other cholesterol-lowering drugs don't have that same track record.
So, why are some highly respected heart specialists saying whoa, not so fast, to the new cholesterol and statin guidelines?
The previous guidelines recommended treatment of high cholesterol to reach a specific goal number. Even if it meant taking a statin plus additional cholesterol-lowering drugs. And there really is no evidence that taking more than a statin just to reach that goal makes a difference in a person's future health.
The new guidelines recommend a statin based on heart disease and stroke risk. A statin is recommended for:
- Anyone who has cardiovascular disease, including angina (chest pain with exercise or stress), a previous heart attack or stroke, or other related conditions
- Anyone with a very high leve lof harmful LDL cholesterol (generally an LDL greater than 190 milligrams per deciliter of blood [mg/dL])
- Anyone with diabetes between the ages of 40 and 75 years
- Anyone with a greater than 7.5% chance of having a herat attack or stroke, or developing other forms of cardiovascular disease in the next 10 years
The questioning heart doctors actually agree with the approach of the new guidelines. That is, doctors should prescribe a statin based on a person's risk of heart disease and stroke rather than a goal number. And they definitely agree that anyone in the top 3 categories should be on a statin drug.
The concern revolves around the calculator used to determine a 7.5% heart attack or stroke risk. The calculator likely over estimates that risk for many people who won't benefit from taking a statin drug year after year. The worry is that millions of otherwise healthy people will be taking a drug long term with its potential side effects and no health benefit to them.
What Changes Can I Make Now?
You should definitely be taking a statin a drug if you fall into categories 1, 2 or 3 above. The big question facing millions of people is what to do if they are otherwise healthy and have no significant risk factors for heart disease or stroke.
In addition to diabetes, the major risk factors include:
- Smoking or regular use of other tobacco products
- High blood pressure
- A family history of coronary heart disease before age 55 in men and 60 in women
But what if your cholesterol is high, but your LDL (bad) cholesterol is less than 190 mg/dL and you have no other risk factors? Should you take a statin?
At this time, there is no best answer. For now, I will suggest the following for my patients that just have a high LDL cholesterol. First, try to lower your cholesterol with a Mediterranean-style diet and exercise. Lifestyle changes should always be a priority even if you need a statin.
If the LDL is still greater than 160 mg/dL, I will suggest taking a statin drug. And if a person with a lower LDL cholesterol level, say 130 – 159 mg/dL wanted to take a statin, I would prescribe it. And I might even consider a statin for some people with even a lower LDL.
What Can I Expect Looking to the Future?
Near term, it will take some time for doctors to adjust to the new guidelines. Without specific number targets for LDL cholesterol, it's no longer clear what dose of a statin is the right one.
Choosing which statin to take is easier. The ones with the best evidence for heart attack and stroke include simvastatin, atorvastatin and rosuvastatin. Simvastatin and atorvastatin are available as generics.
Long term, genetic testing will determine your individual heart and stroke risk. Then your doctor can make a personal recommendation to you regarding your need for a statin.