Should you be taking a cholesterol-lowering statin?
Cholesterol used to be all about your number, but that’s changing. New guidelines from the American College of Cardiology and the American Heart Association could mean that you’ll leave your next doctor’s visit with a prescription for a cholesterol-lowering statin medication. To learn more about the new guidelines, we talked with George Rodgers, MD, FACC, a cardiologist in private practice in Austin, Texas to find out how this significant change could affect you.
Q: How are these new guidelines different from the way doctors managed cholesterol and assessed heart attack risk in the past?
Dr. George Rodgers (GR): Doctors used the Framingham risk calculator, which assessed the risk of a heart attack based on your total cholesterol level, HDL cholesterol level, whether you smoked and your systolic blood pressure. The goal was to reach an LDL cholesterol level of below 100 mg/dL (milligrams of cholesterol per deciliter of blood) of LDL cholesterol or 70 mg/dL if you were at high risk for a heart attack.
The new guidelines and risk calculator expand the focus to include a broader measurement of heart attack risk. Under these new guidelines, doctors will calculate each person’s risk of having a heart attack over the course of the next ten years based on several factors:
- age
- sex
- race
- cholesterol levels
- blood pressure
- whether you have diabetes
- whether you’re being treated for high blood pressure
- whether you smoke
If your risk is greater than 7.5 percent, the recommendation is that you should take one of the drugs in the statin category.
Q: How were the new guidelines developed?
GR: An expert panel led by Neil J. Stone, MD, Bonow Professor of Medicine at Northwestern University Feinberg School of Medicine, spent three years reviewing the results of randomized controlled population studies that looked at heart attack risk and pooled the information gathered in these studies to develop the new guidelines and risk calculator.
Q: If you’re at high risk under the new guidelines, what is the recommended treatment approach?
GR: If you are at more than a 7.5 percent risk of having a heart attack in the next ten years, it’s recommended that your doctor prescribe a high dose of a high intensity statin with a goal of reducing your LDL cholesterol level by 50 percent, no matter what your current LDL level is. With the old approach, a physician might say, “Your LDL cholesterol is at 70, you’re following a heart healthy diet, so you probably don’t need a statin or your cholesterol can be managed with a non-statin medication.”
But the new guidelines say the protection against heart attack comes from the statin and its anti-inflammatory effects. Atherosclerosis (when plaque builds up in your arteries and limits blood flow to your heart and other parts of the body) involves plaques that are inflamed and can rupture, causing a heart attack, so the statin reduces the inflammation and the risk of rupture.
Q: What if you’re at an intermediate risk according to the new guidelines?
GR: If your risk is near 7.5 percent, it’s helpful to use additional risk assessment tools to get a clearer picture. These tools can include coronary artery calcium scoring and ankle brachial index testing, which measures your blood pressure at the ankle and arm and assesses your risk of peripheral artery disease, another risk factor for heart attack and stroke.
Q: What is your opinion of the new guidelines?
GR: I think statins are very powerful, very effective drugs and I agree with the new guidelines. Since I started in medicine 25 years ago, I’ve seen an overall 30 percent reduction in heart attack deaths due more to the increased use of statins than to aggressive surgical approaches to treat heart disease.
Q: There have been some physicians who say they think the calculator overestimates risk and could mean more people will be prescribed statins than actually need them. Do you agree with that assessment?
GR: I don’t think it does overestimate risk. The data has been scrutinized for three years by the most sophisticated epidemiologists we have. They are very cautious in their recommendations and the new guidelines are supported by the data. I believe this will be widely adopted by doctors and become the standard of care in the near future.