As you may of heard, some experts created new guidelines for clinicians to treat high cholesterol, and they have generated quite a bit of controversy, since they are a big departure from prior guidelines. The big new difference is that they no longer emphasize having “target” levels of cholesterol, LDL, etc and rather focus on just using statins at low, moderate, or high doses based on the patients level of “risk”, which is calculated from a formula based on age, sex, and various risk factors. This could be a sound approach, since some experts feel that simply being on a statin will reduce heart risk, regardless of how much a patients “numbers” actually change. They also conclude that most other types of cholesterol medications, besides statins, don’t have much impact on heart disease and are not generally recommended. The controversy is that the recommended formula to calculate an individual’s long-tern risk has not been thoroughly tested, and it seems to overestimate risk in many groups of patients.
What messages can we “take home” from these new guidelines? Here are a few:
1. The best treatment for high cholesterol remains lifestyle – diet and exercise.
2. The decision to start medication therapy should be individualized and come from the patient, after a thorough discussion with their clinician about risk.
3. Patients with established heart disease clearly benefit from statin therapy, which clearly reduces future risk of heart attack and stroke.
4. For patients without a history of heart disease or stroke,the benefit may be very negligible, unless they fall in a “high risk” group based on other risk factors such as diabetes. These patients should discuss the pros and cons of medication therapy with their doctor.
4. One way to think of statin therapy: it reduces future risk of heart attack and stroke by one-third in everyone. That means a 300 lbs diabetic who just had a heart attack, and a 30 year old fitness fanatic in perfect shape. The difference is the baseline risk. If you start with a risk of 1 in 100 of a heart attack the next 5 years, is that 1/3 reduction really worth taking a potentially toxic pill every day? Probably not. But 1 in 10, or 1 in 5? Probably yes.
So if you have been recommended therapy, or already on therapy, for high cholesterol, ask your doctor about your cardiovascular risk both with and without medication. And more importantly, stay active, maintain your weight, and focus on your diet!
Here is an some excellent summaries of the debate about the new cholesterol guidelines:
Dr. Krumholtz discussion in New York Times
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