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Harvard Commentaries
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School

Man to Man Man to Man

Q&A -- The New Cholesterol Guidelines

December 20, 2013

By Harvey B. Simon M.D.

Harvard Medical School

Heart disease is the leading cause of death in America. For the past 50 years, doctors have focused on lowering blood cholesterol levels to prevent heart disease.

Since 2002, doctors have relied on guidelines that call for reducing cholesterol to specific target levels. As a result, a man's risk of dying from a heart attack has continued to fall. 

Then in November 2013, the American Heart Association (AHA) and the American College of Cardiology (ACC) issued a new set of guidelines for cholesterol that raised many questions.  Here are some questions men have been asking me — and some answers that may help restore confidence and calm.

What Is Coronary Artery Disease?

Coronary arteries disease (CAD) is a major form of atherosclerosis ("hardening of the arteries"). It develops when cholesterol enters the artery wall. Over time, the cholesterol builds up into fatty deposits called plaques. This is most likely to happen when cholesterol levels are high, and when the artery wall has been damaged by another problem (such as high blood pressure or diabetes). And as the cholesterol deposits build up, they trigger inflammation. This adds to the damage and risk of a heart attack.

If a plaque produces enough narrowing, your heart muscle can't get the blood it needs to meet the extra demands of exercise, cold, strong emotion and other stresses. That's what causes the chest pain of angina. If a plaque ruptures, it triggers  a blood clot to form on its surface. The clot closes off the artery completely, depriving the heart muscle of its blood supply. Muscle cells that depend on the blocked artery die, producing a heart attack. 

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Does Cholesterol Still Matter?

Men who have heard a few sound bites about the new guidelines may be tempted to shrug off cholesterol altogether.  Don't make that mistake!  In fact, the AHA and ACC report strongly confirms that cholesterol still counts, and that high levels of LDL ("bad") cholesterol is a major culprit in CAD and other forms of atherosclerosis. The experts still agree that lowering LDL cholesterol can protect your heart.

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What about the "Good" Cholesterol?

High levels of LDL ("bad") cholesterol increase the risk of heart disease, but high levels of HDL ("good") cholesterol appear to reduce risk.  But the new report doesn't have much to say about HDL.  That's because the statins don't have much effect on HDL—and the drugs that do boost HDL don't protect the heart.  That doesn't mean you should forget about HDL.  Instead, boost your HDL the natural way with exercise, weight control, a low-sugar diet, and perhaps low-dose alcohol (see "Lifestyle Changes Still Come First").

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So, What Has Changed?

The new guidelines should reassure men that the basic things still apply. But they do make important changes in how doctors manage cholesterol, such as:

  • The name of the game is reducing the risk of heart attacks and cardiac death, not having nice lab results.
  • Prevention starts with lifestyle changes that protect the heart, not with simply lowering cholesterol with medication (see below).
  • Men who are at the highest risk of heart disease will benefit most from lowering their cholesterol. There are many cholesterol-lowering medicines available. They include statins, fibrates, resins, niacin and ezetimibe. All of these drugs can improve cholesterol. But ONLY the statins actually reduce the risk of heart attack and other cardiac events. So the new guidelines call for a statin when medication for cholesterol is needed.
  • Lowering LDL cholesterol is indeed important, but there is no scientific evidence to support focusing on specific LDL target numbers.  As a result, the new guidelines abandon the familiar widely-used targets. This is a big change. Still, the AHA-ACC experts agree that when it comes to LDL cholesterol, lower is better.  So in place of targets, they recommend more intensive statin therapy for people who need the most help.

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Who Should Take a Statin?

The new guidelines identify four groups of people who will benefit from statin therapy:

  • People with clinical signs of atherosclerosis. This includes everyone who has had angina, a heart attack, a stroke or "mini-stroke" (transient ischemic attack, or TIA), or peripheral artery disease. These patients will benefit from a statin even if they have normal LDL levels before treatment. In this group, statin therapy is a form of secondary prevention, meaning it's designed to reduce the likelihood of additional harm from a disease that is already present.  In the other groups, though, statins are used for primary prevention, to reduce the odds that heart disease will develop in the first place.
  • People with LDL cholesterol levels that are dangerously high, 190 mg/dL or above. 
  • People between the ages of 40 and 75 who have diabetes and LDL levels above 70 mg/dL.
  • People between the ages of 40 and 75 who do not have diabetes or atherosclerosis, but who have LDL levels above 70 mg/dL and an estimated 10-year risk of heart disease of 7.5% or above. It's the trickiest and most controversial recommendation, since it may mean statin therapy for many men who seem perfectly well.

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How Do I Know my Risk?

It's another good question, but it doesn't have a simple answer.  For years, doctors have relied on the Framingham Risk Calculator to estimate risk. It's a simple test that has been useful. But the AHA-ACC panel created another risk calculator that's designed to identify more people who need protection but don't know they are at risk.

It will take some time to learn which approach is best. And it's a good reminder that doctors should always prescribe medication on an individual basis after discussing the pros and cons of therapy.  (In next month's column I'll give you tips to hold up your end of that conversation.)

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How Do I Decide if I Need a Statin?

Discuss your situation with your doctors. (Give them some time to get up to speed on the new guidelines.) Talk to family and friends, too.  To help you along, next month I'll compare the seven statin drugs, and discuss dosing and safety.  But before zeroing in on statins, you should be sure you are doing everything you can to protect your heart by living right.  If you succeed, you may not ever need a statin.

And for the record, although I was in excellent health, I started a statin on the advice of my doctor when I turned 60.  Most cardiologists I know take a statin.

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What about the Side Effects of Statins?

Statins are both safe and effective, but like all medicines they can have side effects.  These include muscle aches, liver inflammation, elevated blood sugar levels, and other, even less common reactions.  In most cases the side effects are mild and resolve promptly when the statin is stopped or the dose reduced.  All in all, experts agree that for the four groups of people listed above, the benefits of statins outweigh their risks.

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Lifestyle Changes Still Come First

Every patient with coronary artery disease needs to follow a heart-healthy lifestyle. And the same good habits can prevent heart disease from getting started in the first place. Here's what I advise:

  • Avoid tobacco in all its forms, including secondhand smoke.
  • Change your diet. Eat less saturated fats and cholesterol by limiting meat, whole dairy products and eggs. Avoid trans fats. This is getting easier by the day since these partially hydrogenated vegetable oils are rapidly disappearing from margarine, fried foods, snack and "junk" foods. Use olive and canola oils. Eat lots of fish. Choose whole grain products instead of refined grains and simple sugars. Eat lots of fruits and vegetables. Cut down on sodium (salt). If you enjoy alcohol and can drink responsibly, limit it to one or two drinks a day.

  • Stay active.  Spend at least 30 minutes a day walking, biking or doing other forms of moderate exercise. People with CAD need medical clearance and may benefit from supervision.

  • Control your weight. If you need to reduce, cut down on the calories you eat and boost the calories you burn with exercise.

  • Reduce stress. Simplify your life as much as possible. Learn relaxation techniques. Ask your doctor about help if necessary.

  • Consider aspirin, an important medicine that helps prevent artery-blocking blood clots. All it takes is 81 milligrams (a baby aspirin) a day. Unless there is a specific reason not to take aspirin (such as ulcers, bleeding or allergies), every patient with CAD should take low-dose aspirin. In fact, if you think you may be having a heart attack, you should chew and swallow a full, uncoated aspirin tablet even before you call 911. Men who are at high risk for heart disease should also consider low-dose aspirin.

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Harvey B. Simon, M.D. is an Associate Professor of Medicine at Harvard Medical School and a member of the Health Sciences Technology Faculty at Massachusetts Institute of Technology. He is the founding editor of the Harvard Men's Health Watch newsletter and author of six consumer health books, including The Harvard Medical School Guide to Men's Health (Simon and Schuster, 2002) and The No Sweat Exercise Plan, Lose Weight, Get Healthy and Live Longer (McGraw-Hill, 2006). Dr. Simon practices at the Massachusetts General Hospital; he received the London Prize for Excellence in Teaching from Harvard and MIT.

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