New cholesterol guidelines: The statin decision lies with patients

New cholesterol guidelines: The statin decision lies with patients

The release of the new cholesterol guidelines from the ACC/AHA is big news.  It represents a fundamental shift in how we prescribe statin drugs.

As with many sweeping changes, there are some good, and some controversial ideas.

I like removing non-statin cholesterol drugs from the recommendations, such as Zetia.  Many haven’t been shown to save lives or decrease cardiovascular events.

Also, removing LDL targets can simplify how we monitor those on statins.  For instance, there is no longer a need to pile on statin therapy to chase an arbitrary target number.

(Although some cardiologists, like the Cleveland Clinic’s Steven Nissen says targets can help motivate patients: “I have worries about how to motivate patients when they don’t have numbers as goals … The targets served a purpose for sure even though they weren’t scientific.”)

The guidelines stratify patients into 4 broad categories:

  • Those with a history of atherosclerotic cardiovascular disease
  • Those with an LDL cholesterol level of 190 mg/dL or more, which includes many patients with familial hypercholesterolemia
  • Patients with diabetes ages 40 to 75 who do not have a history of clinical atherosclerotic cardiovascular disease and have an LDL cholesterol level of 70 to 189 mg/dL
  • Those with a 10-year cardiovascular risk — assessed using the new equation — of 7.5% or higher and an LDL cholesterol level of 70 to 189 mg/dL but no history of cardiovascular disease

It’s the last category I want to focus on, since it has the potential to greatly increase medication use among those without cardiovascular disease.  Some say by more than 50%.

Previously, we would consider statin use in those calculated to have a 10-year cardiovascular risk that was significantly higher — about 20%.  Lowering that percentage obviously increases the number of candidates for a statin.

(As an aside, the new calculator is also cumbersome to use.  In the age of mobile devices, it would have been nice for the ACC/AHA to release a mobile version.  Who has time to download and use an Excel spreadsheet during a patient visit?)

Already, there is concern about this expanding pool of patients.  Consider what cardiologist Eric Topol says:

For people with no history of heart disease, but who are trying to prevent heart disease, there is already a tremendous amount of overuse of statins in my view in this country … So my concern is that the new guidelines will lead to potentially even more promiscuous use of these statins than already exists.

Also, emphasis on statins will be at the expense of lifestyle changes, such as diet and exercise. The dwindling office visit time given to primary care doctors practically guarantees that.

Here’s my bottom line.

In those with diabetes, cardiovascular disease, or an LDL of 190 and above, strongly advise starting a statin.

In others without disease, have them take the risk calculator, then discuss the risks and benefits of statin therapy.

Remember, the ultimate decision on whether to start a statin lies with patients.

Cardiologist Harlan Krumholz has a good take in the New York Times, where he recommends 3 questions all patients should ask their doctors.

But in the end, he also recommends a shared decision:

I believe that only you can determine what constitutes a high enough risk that it is worth it to you to be treated with drugs. Such a decision depends on how you feel about your risk of heart disease and stroke and how you feel about taking drugs — and their risks and benefits.

New cholesterol guidelines: The statin decision lies with patientsKevin Pho is an internal medicine physician and co-author of Establishing, Managing, and Protecting Your Online Reputation: A Social Media Guide for Physicians and Medical Practices. He is on the editorial board of contributors, USA Today, and is founder and editor,, also on FacebookTwitterGoogle+, and LinkedIn.

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  • Carolyn Thomas

    This goes without saying, but the fact that fully half of the authors of the guidelines are on the payroll of the drug companies that make statins is problematic. In fact, as quoted by teh Associated Press: “It is practically impossible to find a large group of outside experts in the field who have no relationships to industry” said Dr. George Mensah of the NHLBI (the same organization that famously issued guidelines two years ago calling for universal cholesterol screening of all nine-year old children – )

    If this were professional sports instead of health care, umpires and referees who admitted taking money from team owners would be turfed, not called upon for their “expertise”.

    Admitted financial conflicts of interest may also explain why aspirin – widely used to lower the risk of strokes and heart attacks – is not addressed at all in these guidelines.

    So twice as many Americans who are currently taking statins – that’s one-third of ALL adults – may now be told to consider taking these drugs every day for the rest of their natural lives, all of this very good news indeed for Big Pharma whose member companies must be giddy with joy today.

    • Chiked

      Could not have said it better. I am clipping these articles so I can one day show my grandchildren how corrupt our medical system was.

      Shame on any doctor for going along with this charade. Everyday you reduce the worth of your profession.

    • James_04

      I know a doctor who regularly prescribes statins to just about all of his patients over 40. I’ve heard him quip several times that he loves statins so much and thinks they’re such a wonder drug, he’d “add them to the water supply” if he could. That sort of sends a chill up my spine.

  • James_04

    “Remember, the ultimate decision on whether to start a statin lies with patients.”

    And to make an informed decision about that, patients need more information than just “take this, it’s good for you”.

    They need honest information about the financials of the statin industry, and who they’re funding and how that might be influencing decisions.

    They also need honest information about the side-effects of statins, which I don’t think a lot of people are really getting. These are not harmless sugar pills, they can have very real and very negative side effects. Patients need to be able to do a cost-benefit analysis, “are the potential benefits of this drug worth what else it might do to me?”, but it seems like they’re being fed mainly the “benefit” side of things and not being well informed about the potential “costs” to their health in other ways of taking these drugs.

  • JPedersenB

    Read the op-ed piece in the NY Times on this subject.

  • Frank Lehman

    I went to the American Heart Assoc risk calculator (using the link provided above).

    When I enter my info, it says I have a 10 yr risk (I am 70 so it will not provide a lifetime risk) of 21%. This is with all my values (total Cholesterol, HDL, blood pressure, no treatment for blood pressure, no diabetes, non smoker) within the optimal range.

    I tried entering other values to see what I needed to improve to get me to a 7.5% risk. I entered 130 for total cholesterol (it will not accept a lower figure), 100 for HDL (it will not accept a higher figure), 103 for blood pressure, and, of course, I am still a white, male,70 years old, still have no treatment for high blood pressure, still no diabetes, and still a non-smoker). That got me down to 7.5%. The only way to do better than 7.5% is to get the blood pressure even lower (it will not accept a value below 90, so I do have room for improvement there).

    Obviously, I have no ‘hopes of ever being able to improve things enough to get me to the 7.5% level.

    It is also noteworthy that all the values I used to get that 21% figure were well within the “Acceptable Range of Values” shown on the calculator.

    What is the conclusion here? They have come up with a “Risk Calculator” that is virtually certain to require that all men anywhere close to my age should be on statins.

    The other interesting thing is that if I were African American my risk would be a lot less (about 13% instead of 21%), even though everyone else seems to say that African American men are at greater risk.

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