Long-awaited and much-delayed, new cholesterol guidelines were released by an expert panel from the American College of Cardiology and the American Heart Association in November. These replace official guidelines that were last updated a decade ago. In effect, they set aside numeric targets for cholesterol and focus instead on treating people (possibly many more people) who are deemed to be at elevated risk for cardiovascular disease (CVD) and are most likely to benefit from treatment—with the emphasis completely on treatment with statin drugs.
The reaction from other experts, practicing physicians and the media was swift and often heated. While some have welcomed the changes, others strongly disagree with them.
The guidelines could potentially upend decades of medical practice. It will take months or even years for the dust to settle, during which time the guidelines will be reassessed and possibly altered. Keep in mind that the new guidelines, like earlier ones, are just starting points. They are intended to help you and your doctor (or other health care provider) make decisions, not dictate them.
New approach to managing risk
Based on a systematic review of evidence, with special weight given to well-designed clinical trials, the cholesterol guidelines appear in one of four reports. The other three sets of guidelines pertain to assessing CVD risk, lifestyle management to reduce CVD risk (covering diet and exercise) and obesity treatment.
There is little new in the guidelines about a heart-healthy diet (plant-based, low in saturated fat and sodium), physical activity, and body weight, so they got minimal media attention. All eyes were on the new cholesterol guidelines and the risk assessment tool, which were radically changed.
For the last quarter century, Americans have focused on their cholesterol numbers, encouraged to do so by guidelines that set specific numeric targets—for instance, that total cholesterol should optimally be under 200 and LDL “bad” cholesterol should be under 130 or even under 100 or 70, depending on the individual’s level of risk. However, because no studies have been done to assess the benefits of achieving these targets, the new guidelines do not include such goals (actually, they don’t recommend for or against them) and say that treatment should no longer be tailored to reach them. The guidelines still emphasize lowering LDL, just not to specific targets.
The new focus is on four high-risk groups, for whom statins are recommended:
- People with pre-existing CVD, such as those who have had a heart attack, angina, stroke or TIA (transient ischemic attack, or mini-stroke).
- People ages 40 to 75 who have diabetes (which greatly increases CVD risk).
- People with very high LDL (190 or above).
- People ages 40 to 75 without CVD or diabetes who have a 10-year risk of CVD of at least 7.5 percent, based on a new online assessment tool (see box at end).
There’s no debate that people in the first three groups should take statins—that has long been standard practice (though some experts believe the LDL cutoff should be lower than 190, especially for people with other risk factors). It’s the assessment tool that has been most controversial, largely because it may greatly expand the number of candidates for statins.
The new guidelines recommend only statins because, the panel concluded, other cholesterol-lowering drugs (such as niacin or fibrates) are of unproven benefit against CVD and thus should be considered only for people who can’t tolerate statins. They specify optimal dosing for various statins, based on risk profile. Most statins are now off patent and available as inexpensive generics.
For people started on statins, the guidelines still advise periodic cholesterol measurement, to check for adherence to the drugs and assess the effects of diet and other lifestyle factors that can affect cholesterol levels.
What about older people?
The treatment guidelines focus primarily on people ages 40 to 75 because almost all of the major clinical trials have involved that age group. They do advise people under 40 or over 75 with CVD or very high LDL to take statins; for others in these age groups, the benefits and risks of statin therapy should be considered on an individual basis. Doctors are advised to be cautious in starting statin therapy in those over 75 without CVD. Even though older people have the highest risk of heart attack and stroke and thus have the most to gain, they’re also most likely to suffer adverse effects from statins, largely because of medical conditions they have and interactions with other drugs.
We are hesitant to endorse the new guidelines. It’s not clear that this approach—especially its emphasis on the risk calculator—will actually be more effective than the previous target-based guidelines. In any case, it’s not known how eagerly or quickly the new guidelines will be adopted by doctors and other health care providers. Many will probably keep using the old cholesterol targets, or meld them with the new guidelines—particularly if the targets help keep patients motivated to make lifestyle changes and/or take their statins.
Don’t let the debate about the guidelines deter you from getting a cholesterol screening and CVD evaluation. The great majority of people who would be prescribed statins under the new guidelines would have been prescribed them under the old ones as well. In cases where the decision is less clear, “clinician knowledge, experience and skill, and patient preferences, all contribute to the decision to initiate statin therapy,” the guidelines state.
It’s essential to talk with your health care provider about your CVD risk factors and how you can modify them, as well as the potential benefits and risks of statins, if you’re a candidate for one. Statins can cause muscle pain and weakness and slightly increase the risk of elevated blood sugar and diabetes.
Finally, while statins have played a major role in the dramatic decline in mortality rates from heart disease since the 1980s, they can’t replace a healthy lifestyle. An abundance of research supports the benefits of a heart-healthy diet (such as the Mediterranean diet or DASH plan), exercise, not smoking and weight control—which not only improve cholesterol levels, but also help protect cardiovascular health in other ways. Even if you take a statin, these steps are still essential.
Published March 18, 2014