How to talk to your doctor about cholesterol

I’m not going to discuss the entire subject of cholesterol in this post, but one part of it: specifically, how to discuss with your doctor how much cholesterol should matter to you.

If you have read any health news recently, you know that the American College of Cardiology and the American Health Association issued new guidelines to help doctors advise patients about cholesterol medications. The new recommendations are accompanied by a calculator of heart risk into which one enters various laboratory and personal characteristics: whether you smoke, have diabetes, have high blood pressure, and the like.

Unfortunately, a kerfuffle has ensued over some errors present in the calculator. Millions of Americans, under the new guidelines, might be recommended to receive cholesterol medications, and this massive expansion of the medicated populace is under dispute.

Putting that aside, however, we will focus here on an even more basic question: how do you know what level of heart risk is important to you? Any recommendations about whether or not to use a cholesterol medication — the old ones and the new ones — depend on the application of calculation to you. The doctor will calculate the risk in the next 10 years that you will have a heart attack, and use that number to decide whether you should be taking a cholesterol medication.

However, that assumption crumbles the harder you press on it. First you should discuss with your doctor whether you are in one of the high-risk categories that places you at significant risk of heart disease in the first place: a family history of early heart disease or stroke; or a history of diabetes in yourself. Perhaps, on the other hand, you are generally healthy and your risk of heart disease is low; this is probably most people. A significant proportion will fall somewhere in the middle.

But even if your risk lies at one of these two extremes, and your doctor is confident in telling you that your risk of heart disease is high (or low), there is one essential point to keep in mind which is underemphasized in all the media coverage of the new cholesterol guidelines:

Whether to take such a medication is still, and always, your decision.

This is not “your decision” in the sense of: go play in traffic, see if I care. Rather, your decision-making must take into account a whole variety of factors, which can be clarified by thinking about the following questions, or discussing them with your doctor.

Cholesterol medications can reduce the rate of heart disease, but there’s a difference between absolute rate reduction and relative rate reduction. If a cholesterol medicine reduces your rate of heart disease by 50%, that sounds great, but it’s less impressive if your 10-year chance of developing heart disease was only 5% to start with. Maybe you can live with a 10-year chance of developing heart disease that’s 5 in 100. So you might ask: “What is my baseline risk of developing heart disease, without a cholesterol medication?”

Cholesterol medications can cause side effects not uncommonly. Some studies cite a rate of 10% for the rate of muscle-related symptoms (this is probably the upper range of the rate, including everything from muscle aches all the way to significant muscle inflammation). You are really the only one who can weigh the chance of side effects to the benefits of the medication. But you might ask, “How would you compare the risks and benefits of this cholesterol medication?”

Finally, it’s important to realize the imperfect nature of all guidelines. A guideline is merely a compendium of recommendations, and a recommendation can only be useful and relevant to you if two things are true: (a) it is based on good scientific evidence; (b) this evidence is relevant to your particular needs, sensitivities, and circumstances. About (a), you should ask your doctor, “How confident are you in the scientific evidence that backs up this recommendation?” Pay particular attention, for example, to how they understand the balance between risks and benefits in the subpopulation (i.e. the risk category) you fall into.

With regard to (b), of course, you are the only one who can make that determination, and no guideline can substitute for your considered, informed decision.

Zackary Berger is an internal medicine physician.  He blogs at his self-titled site, Zackary Sholem Berger, and is the author of Talking to Your Doctor: A Patient’s Guide to Communication in the Exam Room and Beyond.

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  • Kaya5255

    Thank you putting in writing that is the healthcare consumer’s final decision to take or not take statin drugs. Far too many practitioners keep pushing and really can’t take “NO” for an answer.

    • Zackary Sholem Berger

      Thank you. Whenever new guidelines appear, I have to remind myself that there are decision aids available which use guidelines the way they should be used: as recommendations to help patients in their decision making.

    • JPedersenB

      Actually, most physicians will never take “No” for an answer. They do not recognize that taking a drug (especially a controversial one) is the patient’s decision. Too many will label the person as “non-compliant” and drop that person from the practice…

      • Kaya5255

        You’re probably right that too many practitioners can’t take no for an answer and label customers as non-compliant to drop them from the practice. My take is that they’ve probably done you a huge favor. Use the opportunity to find a new practitioner. Also suggest that you schedule an “interview” appointment and make sure that you and the new person are on the same wave length and that there is no misunderstanding that you and you alone make the final decision on any medications and/or procedures.

  • Dorothygreen

    You used 5% in 10 years as the risk one could live with for a heart attack. Did you do the calculation? 7% is the RED LINE. And, with everything else in one’s life constant except a birthday one can go from 7 to 7.5% that dreadful day.

    This is consistent with the actuary calculations of increasing the cost of health insurance on the exchange. Happy birthday, your premiums increased. Oh! by the way, There is another increase because so many need statin drugs.

    Can you see this is not just a doctor and patient thing? But rather clever American calculations, complex derivatives developed by Quants that brought the economy down in 2008, It will make both health insurance and pharmaceutical companies overcome any careful regulation. Health care costs will rise again and have their turn to bring the economy down.

    I will resist and probably be put on the “non-complaint” list, when, at 77 I reach that 7.5% – kicked off my Medicare, while riding my bike and eating homemade Kale chips long before I even get a chance to use all the money I put in. It will go to those who are complaint with their drugs, much younger than me who have proudly used my share on treatment for their preventable heart disease and diabetes.

    This is the American way.

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