In November 2013, the American Heart Association released new guidelines on how doctors could best manage cholesterol levels in their patients. It's the first time in a decade that these guidelines have been updated.
The new guidelines change the way doctors determine who should take statins, a class of drugs prescribed to lower cholesterol. According to the new parameters, as many as one-third of all adults in the United States could benefit from taking statins. That's a much higher number than indicated by the previous guidelines. Also, unlike their predecessors, the new guidelines advise doctors to focus less on cholesterol levels and more on overall heart disease risk when deciding on statin therapy.
Statins: Who Needs Them?
Doctors have long prescribed statins mostly based on a number - namely, cholesterol count. if you had a too-high level of LDL "bad" cholesterol, you would be a candidate for statin therapy.
The new guidelines shift the focus from cholesterol count to total risk. It asks doctors and patients to take a broader view than just the LDL level, says Duke cardiologist Mahesh Patel, MD. "Your risk of having a heart attack or stroke is a complicated thing," he says. "You have to take into account age, gender, race, both total and HDL 'good' cholesterol, smoking, and other health conditions such as diabetes and hypertension." So while the cholesterol count from your latest blood work is still a factor, it's no longer the driving factor.
The new guidelines list four groups of people who should be strongly considered for statin therapy:
- People with a history of heart attack, stroke peripheral artery disease, or other heart or vascular problems
- People 21 and older who have a very high level of bad cholesterol (an LDL of 190 or higher)
- People with type 1 or type 2 diabetes who are 30 to 75 years old
- People ages 40 to 75 who don't have heart disease but do have a 7.5 percent or higher risk for having a heart attack or stroke within 10 years, according to a new risk calculator that measures a variety of lifestyle and physical factors.
Why the change?
Plenty of research has been conducted over the years examining the effects of cholesterol-lowering therapies. Not all studies were created equal, however. Patel explains that the authors of the new guidelines chose not to include studies that were of lower quality. "The current guidelines were based solely on high-quality, randomized, controlled clinical trials.
"If you meet the criteria for needing treatment, the new guidelines focus on matching your risk with the appropriate intensity of statin therapy - whether you require a high, moderate, or low dose of statins," says Patel. Previously, the goal was getting LDL levels to less than 100 or 70. "There really is no strong evidence to show that treating to a specific LDL number is best for all people, so the guidelines shift our focus to assessing risk. New trials may be performed in the future to test the hypothesis of treating to specific LDL goals, but presently there is no strong evidence to support this approach."
Benefit and Risk
Patel cautions that the guidelines aren't meant to be taken as more than what they are - guidelines. "They don't absolutely determine whether you need statins," he says. They help guide the conversation as the patient and physician make the decision together. Everyone is different."
It all comes down to weighing risks and benefits. "I always come back to this," he says. "There are real side effects to statins, but almost all of these side effects are reversible and non-life-threatening. You can't say the same about the 'side effects' of not taking statin drugs when you are at high risk for heart attacks and stroke."
The Real Story
Perhaps the most important and overlooked issue in these guidelines is lifestyle change, Patel says. "That is always the first option. These guidelines say that a healthy lifestyle should always accompany statin therapy. That means eating healthy, eating less, moving more, and not smoking. We've learned that there are a lot more questions that need to be answered and many more studies that need to be done, but a healthy lifestyle is always going to be a wise, affordable, and positive change to make."