New Cholesterol Drug Guidelines: Q&A
By Kathleen Doheny
Reviewed by Arefa Cassoobhoy, MD, MPH
Nov. 14, 2013 -- The question of the day is: Should I be on a statin?
New guidelines released Tuesday by the American Heart Association and the American College of Cardiology change the standards for who should be taking these cholesterol-lowering drugs.
As doctors follow the new guidelines, more people are expected to be put on statins.
The guidelines include new weight and lifestyle measures to lower the risk of having a heart attack and stroke. The guidelines also recommend that doctors focus on overall risks to the heart and less on cholesterol numbers.
Three doctors give their perspectives on the guidelines.
Q: What's behind the change?
"The new focus is on risk" rather than simply a cholesterol number, says Timothy Henry, MD, director of cardiology at the Cedars-Sinai Heart Institute. "This is a plan for dealing with cardiovascular risk.''
"It starts with knowing what our risk is and then helping to manage that risk, starting with a healthy lifestyle. It starts with exercise, losing weight [if necessary], and eating the right foods. It's also being aware of the risks."
Q: What was wrong with using cholesterol numbers, as we have in the past?
"Nothing was wrong, [it's] just a different approach or focus," Henry says. "Rather than numbers, it's moving the focus to understanding risk and with a focus on a heart-healthy lifestyle.''
Q: Who is likely to get a statin now?
Just as in the past, people diagnosed with heart disease will start taking a statin.
New to the guidelines: People with extremely high LDL, or ''bad'' cholesterol, and all middle-aged people with type 2 diabetes will be advised to take a statin.
Also, men and women 40 to 75 who have an estimated 10-year risk of heart or blood vessel problems of 7.5% or higher will be recommended a statin.
Q: How is that risk determined?
To determine that risk, doctors use a calculator that figures out the chances of having heart problems in the next 10 years. It is also available online here. (You must know your cholesterol numbers and blood pressure to use it.)
The calculator takes into account cholesterol numbers, age, blood pressure, smoking habits, and use of blood pressure medicines. All of these things affect your chance of having heart problems.
The risk calculator does not apply if you already have heart disease.
Q: If people start taking a stain, will they be expected to get their bad cholesterol to a certain number?
Rather than target a specific number, doctors will try to lower your cholesterol by a certain percentage, says Ravi Dave, MD. He is a cardiologist at the UCLA Medical Center in Santa Monica. How much your doctor expects you to lower your cholesterol will depend on your level of risk, he says, and whether the goal is aggressive- or medium-risk reduction.
If you are at high risk, the goal will be to cut the bad cholesterol by half. If you have some risk, your doctor may tell you to lower your cholesterol by 30% to 50%, he says.
Lowering cholesterol in this way helped people avoid heart attacks and strokes in the studies the experts looked at.
"We were much too focused on a number," Dave says. "Patients had to reach a certain number to determine success." Few patients did that, he says.
Q: Did the drug manufacturers have any role in this recommendation?
"None, actually," says Robert Eckel, MD, professor of medicine at the University of Colorado. He was a member of the cholesterol guidelines panel.
"People [on the panels] who felt they were conflicted did not vote on the guidelines," he says.
The expert panel looked at many studies to make its decision, the doctors say. For instance, studies showed that lowering bad cholesterol levels by 30% to 50% in patients at moderate risk could lower their chance of having a heart attack.
Q: Statins have side effects, including muscle aches. Can people try lifestyle changes first?
Living a healthy lifestyle is still important, the doctors agree. "Targeting a healthy lifestyle is the first step," Henry says, "then focusing on the use of statins for moderate- to high-risk patients.''
If your risk is very high, Dave says, your doctor may not give you time to try lifestyle changes by themselves. Instead, your doctor may prescribe medication as well as encourage you to improve your lifestyle.
And some people can't take statins, Henry says, because of side effects.
SOURCES: Ravi Dave, MD, cardiologist, University of California Los Angeles Medical Center, Santa Monica; UCLA director of interventional cardiology. Timothy Henry, MD, director of cardiology, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles. Robert Eckel, MD, professor of medicine, University of Colorado Anschutz Medical Campus, Aurora; co-chair, AHA-ACC lifestyle guidelines panel and member, cholesterol guidelines panel. American Heart Association and American College of Cardiology joint clinical practice guidelines, Nov. 12, 2013.