Cholesterol and statins: it’s no longer just about the numbers

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Updated cholesterol guidelines released yesterday by the American Heart Association and American College of Cardiology aim to prevent more heart attacks and strokes than ever. How? By increasing  the number of Americans who take a cholesterol-lowering statin.

The previous guidelines, published in 2002, focused mainly on “the numbers”—starting cholesterol levels and post-treatment levels. The new guidelines focus instead on an individual’s risk of having a heart attack or stroke. The higher the risk, the greater the potential benefit from a statin.

Statins are a family of medications that lower cholesterol. Even more important, they lower the chances of having a heart attack or stroke. Statins include atorvastatin (generic, Lipitor), fluvastatin (generic, Lescol), lovastatin (generic, Mevacor), pitavastatin (Livalo), pravastatin (generic, Pravachol), rosuvastatin (Crestor), and simvastatin (generic, Zocor). The new guidelines recommend a statin for:

• anyone who has cardiovascular disease, including angina (chest pain with exercise or stress), a previous heart attack or stroke, or other related conditions
• anyone with a very high level of harmful LDL cholesterol (generally an LDL above greater than 190 milligrams per deciliter of blood [mg/dL])
• anyone with diabetes between the ages of 40 and 75 years
• anyone with a greater than 7.5% chance of having a heart attack or stroke or developing other form of cardiovascular disease in the next 10 years.

How is this different from the previous guidelines? They recommended specific cholesterol targets for treatment. For example, people with heart disease were urged to get their LDL cholesterol down to 70 mg/dL. The new guidelines essentially remove the targets and recommend basing treatment decisions on a person’s heart risk profile.

In other words, anyone at high enough risk who stands to benefit from a statin should be taking one. It doesn’t matter so much what his or her actual cholesterol level is to begin with. And there’s no proof that an LDL cholesterol of 70 mg/dL is better than 80 or 90 mg/dL. What’s important is taking the right dose based on heart attack and stroke risk.

There are a few reasons for these new “risk-focused” guidelines:

• Statins are the best drugs to lower LDL cholesterol.
• Statins also have benefits above and beyond cholesterol lowering. We have long known that statins lower the risk of premature death, heart attack, and stroke, even among individuals with relatively normal cholesterol levels—who are not exempt from having heart attacks or stroke.
•  A statin dose tailored to the individual appears to be more important than reaching a particular target number.

Putting guidelines into practice

Will these guidelines change how your doctor checks and treats your cholesterol? Yes and no. Many physicians are already focusing on the balance of benefits and risks when making decisions about treatment. I, for one, am already prescribing statins to patients of mine at high risk of heart disease even when their cholesterol levels are close to normal. What will be new for me is making sure my patients are on an effective dose and no longer focusing on how low their LDL drops.

These new guidelines, while meant for doctors, contain a lot that each of us can do. Here are some examples.

1. Go beyond the numbers. When talking with your doctor, instead of focusing on your cholesterol “number,” ask about your risk for developing cardiovascular risk. That appears to be a better guide as to whether you should be on a statin. Your doctor should have tools to help you estimate that. The new AHA/ACC guidelines recommend replacing the Framingham Risk Score with a new way to estimate risk.
2. Consider the risks. No treatment is without some risk. Statins can cause muscle pain, and in a small number of individuals, more significant muscle injury and rarely liver problems. They have also been associated with increases in blood sugar, which in some cases leads to a diagnosis of diabetes. Some reports have linked statin use to memory issues, but the evidence is unclear. In the end, it’s a matter of balancing the low risk of these side effects with the potential benefit of lower risk of heart disease, stroke, and death. Have an open conversation with your doctor to consider your personal benefits and risks.
3. Remember the other stuff. These new guidelines are quick to remind us that there is more to lowering cardiovascular risk than just taking a statin. We need to remain focused on living healthy as well—eating right, getting exercise, not smoking, and maintaining a healthy weight.

Other guidelines released this week—assessing cardiovascular risk, lifestyle management to reduce cardiovascular risk, and management of overweight and obesity in adults—can help us do this.