Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Applying the new cholesterol guidelines to real life patients

Juliet K. Mavromatis, MD
Conditions
February 5, 2014
136 Shares
Share
Tweet
Share

Cardiovascular disease — including coronary atherosclerosis and cerebrovascular disease — remains the number one cause of mortality in the United States. One out of three people in this country will die of cardiovascular causes.  Although I can’t say that the other top causes of mortality are particularly attractive — cancer, chronic lung disease, accidents and dementia — premature cardiovascular death can certainly be very devastating and it makes sense to do our best to prevent it.

In November 2013, updated guidelines for the treatment of high cholesterol were released by the American College of Cardiology-American Heart Association.  These guidelines were the subject of significant controversy. In contrast to the previous guidelines from 2002, the current guidelines do not suggest treatment based primarily on numerical cholesterol targets. Rather, the guidelines stratify people according to determined cardiovascular risk and recommend either high intensity statin treatment, moderate intensity statin treatment, or no statin treatment. The guidelines do not support using other types of cholesterol-lowering drugs because at this point there is not good data to suggest that using other types of treatments is beneficial in terms of preventing actual cardiovascular outcomes (heart attack, stroke or cardiovascular death). This is despite the fact that there are treatments out there that do lower one’s cholesterol numbers.

How is cardiovascular risk determined?

With the new guidelines, a new risk calculator was proposed. In my clinical practice in the past I’ve used the Framingham Risk Calculatorand the Reynolds Risk Calculator.

The new risk calculator released with the 2013 guidelines is a bit different. Some experts have suggested that it overestimates risk. With the new risk calculator, if one’s ten year risk of a cardiovascular event exceeds 7.5% then treatment with a statin is recommended.

The new guidelines divide people into the following groups of patients between ages 40 and 75 years who are in need of treatment with statins, or so called “statin benefit groups.”

  • Those with LDL over 190mg/dL (high intensity statin treatment is recommended)
  • Those with a ten year risk of >7.5% (moderate intensity statin treatment is recommended)
  • Those with established cardiovascular disease (high intensity statin treatment is recommended)
  • Those with diabetes, in which 10 year risk is >7.5% (high intensity statin treatment is recommended)
  • Those with diabetes, in which 10 year risk is <7.5% (moderate intensity statin treatment is recommended)

What qualifies as high intensity statin treatment? LDL lowering of 50% or greater. What is moderate intensity statin treatment? LDL lowering of 30-50%.

The guidelines suggest that particular statins may be better than others at achieving these goals and good outcomes: atorvastatin, simvastatin, and rosuvastatin.  Other statins are typically used when patients experience unwanted side effects, like muscle pain.
How are things different with the new guidelines?

Let’s take an example.

A 71-year-old white female, non-smoker, non-diabetic, with a history of hypertension, asked me whether or not she should be treated for high cholesterol.  She is concerned about her risk of heart disease, as her mother had a stroke in her 60s and then sudden death, presumed cardiovascular, at age 83.

My patient’s most recent total cholesterol level was 204 mg/dL with an LDL level of 121 mg/dL and an HDL level of 64 mg/dL.  A couple of years ago I calculated her Framingham Risk score, which is 6% with these risk factors. This represents low to intermediate risk.

To get further information I also ordered a coronary calcium score, which was found to be zero.  Last year, based on these numbers and the older guidelines, I recommended against treatment with a statin.  However, now, based on the new risk assessment tool, the same patient has a ten year risk of 16%.  With the new guidelines she would unequivocally qualify for moderate dose statin.

At this point, I am not exactly sure what to do with the coronary calcium score, which probably projects that her risk is lower than the 16% that the new equation came up with.  Nonetheless, I am not sure that coronary calcium scoring entirely predicts all cardiovascular risk — for example risk related to small vessel disease and stroke, so perhaps she should receive treatment. Low dose, statin treatment might be a good compromise here.

Interestingly, based on this new risk calculator virtually every 71-year-old, even with optimal risk factors, would qualify for treatment with a statin.  Herein lies the controversy with this tool.

Nonetheless, my own view of the new guidelines is mostly favorable. To me it simplifies things based on what we know from numerous well designed studies. Treatment, with an emphasis on statins, is based on risk projection and less attention is paid to absolute numbers.  I hope that the next decade will continue to bring more a nuanced understanding of risk.

Juliet K. Mavromatis is an internal medicine physician who blogs at Dr Dialogue.

Prev

Shotgun medicine: An arrow is often better

February 5, 2014 Kevin 3
…
Next

Is the medical home really worth it?

February 6, 2014 Kevin 12
…

Tagged as: Cardiology, Medications

Post navigation

< Previous Post
Shotgun medicine: An arrow is often better
Next Post >
Is the medical home really worth it?

More by Juliet K. Mavromatis, MD

  • a desk with keyboard and ipad with the kevinmd logo

    Drugs that are not FDA approved: Is there a time to prescribe them?

    Juliet K. Mavromatis, MD
  • a desk with keyboard and ipad with the kevinmd logo

    How to know whether alternative medicine is safe

    Juliet K. Mavromatis, MD
  • a desk with keyboard and ipad with the kevinmd logo

    When should drivers retire from driving?

    Juliet K. Mavromatis, MD

More in Conditions

  • Proposed USPSTF guideline update: Advocating for earlier breast cancer screening at age 40

    Hoag Memorial Hospital Presbyterian
  • The rising threat of lung cancer in Asian American female nonsmokers

    Alice S. Y. Lee, MD
  • Urgent innovation needed to address growing mental health crisis among children and families

    Monika Roots, MD
  • The importance of listening in health care: a mother’s journey advocating for children with chronic Lyme disease

    Cheryl Lazarus
  • The unjust reality of racial disparities in pediatric kidney transplants

    Lien Morcate
  • The surprising medical mystery of a “good” Hitler: How a rescued kitten revealed a rare movement disorder

    Teresella Gondolo, MD
  • Most Popular

  • Past Week

    • Physician entrepreneurs offer hope for burned out doctors

      Cindy Rubin, MD | Physician
    • Why doctors aren’t to blame for the U.S. opioid crisis [PODCAST]

      The Podcast by KevinMD | Podcast
    • The power of coaching for physicians: transforming thoughts, changing lives

      Kim Downey, PT | Conditions
    • The hidden factor in physician burnout: How the climate crisis is contributing to the erosion of well-being

      Elizabeth Cerceo, MD | Physician
    • Unlocking the secrets of cancer conferences: an end-of-life counselor’s journey among pharmaceutical giants

      Althea Halchuck, EJD | Conditions
    • We need a new Hippocratic Oath that puts patient autonomy first

      Jeffrey A. Singer, MD | Physician
  • Past 6 Months

    • “Is your surgeon really skilled? The hidden threat to public safety in medicine.

      Gene Uzawa Dorio, MD | Physician
    • It’s time to replace the 0 to 10 pain intensity scale with a better measure

      Mark Sullivan, MD and Jane Ballantyne, MD | Conditions
    • Breaking point: the 5 reasons American doctors are dreaming of walking away from medicine

      Amol Shrikhande, MD | Physician
    • Revolutionize your practice: the value-based care model that reduces physician burnout

      Chandravadan Patel, MD | Physician
    • Breaking the cycle of racism in health care: a call for anti-racist action

      Tomi Mitchell, MD | Policy
    • Unveiling the hidden damage: the secretive world of medical boards

      Alan Lindemann, MD | Physician
  • Recent Posts

    • Master time management with 7 productivity strategies for optimal results

      Farzana Hoque, MD | Physician
    • Proposed USPSTF guideline update: Advocating for earlier breast cancer screening at age 40

      Hoag Memorial Hospital Presbyterian | Conditions
    • The rising threat of lung cancer in Asian American female nonsmokers

      Alice S. Y. Lee, MD | Conditions
    • The tragic story of Mr. G: a painful journey towards understanding suicide

      William Lynes, MD | Physician
    • Healing trauma and reconnecting: Unmasking the impact of dissociation [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why the WHO’s pandemic accord is critical for global health care

      Elizabeth Métraux | Policy

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 1 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • What Was Tied to Lower Long COVID Risk?
  • Chemo-Free Approach Works in Subset of Patients With HER2+ Early Breast Cancer
  • Two-Drug Combo Wins for Refractory Gout
  • First-in-Class Sjogren's Drug Passes Mid-Stage Test
  • Pricey Drug Combo Boosts PFS in First-Line Advanced Ovarian Cancer

Meeting Coverage

  • Chemo-Free Approach Works in Subset of Patients With HER2+ Early Breast Cancer
  • Two-Drug Combo Wins for Refractory Gout
  • First-in-Class Sjogren's Drug Passes Mid-Stage Test
  • Pricey Drug Combo Boosts PFS in First-Line Advanced Ovarian Cancer
  • Cardiovascular Risk Models Still Fall Short for Arthritis Patients
  • Most Popular

  • Past Week

    • Physician entrepreneurs offer hope for burned out doctors

      Cindy Rubin, MD | Physician
    • Why doctors aren’t to blame for the U.S. opioid crisis [PODCAST]

      The Podcast by KevinMD | Podcast
    • The power of coaching for physicians: transforming thoughts, changing lives

      Kim Downey, PT | Conditions
    • The hidden factor in physician burnout: How the climate crisis is contributing to the erosion of well-being

      Elizabeth Cerceo, MD | Physician
    • Unlocking the secrets of cancer conferences: an end-of-life counselor’s journey among pharmaceutical giants

      Althea Halchuck, EJD | Conditions
    • We need a new Hippocratic Oath that puts patient autonomy first

      Jeffrey A. Singer, MD | Physician
  • Past 6 Months

    • “Is your surgeon really skilled? The hidden threat to public safety in medicine.

      Gene Uzawa Dorio, MD | Physician
    • It’s time to replace the 0 to 10 pain intensity scale with a better measure

      Mark Sullivan, MD and Jane Ballantyne, MD | Conditions
    • Breaking point: the 5 reasons American doctors are dreaming of walking away from medicine

      Amol Shrikhande, MD | Physician
    • Revolutionize your practice: the value-based care model that reduces physician burnout

      Chandravadan Patel, MD | Physician
    • Breaking the cycle of racism in health care: a call for anti-racist action

      Tomi Mitchell, MD | Policy
    • Unveiling the hidden damage: the secretive world of medical boards

      Alan Lindemann, MD | Physician
  • Recent Posts

    • Master time management with 7 productivity strategies for optimal results

      Farzana Hoque, MD | Physician
    • Proposed USPSTF guideline update: Advocating for earlier breast cancer screening at age 40

      Hoag Memorial Hospital Presbyterian | Conditions
    • The rising threat of lung cancer in Asian American female nonsmokers

      Alice S. Y. Lee, MD | Conditions
    • The tragic story of Mr. G: a painful journey towards understanding suicide

      William Lynes, MD | Physician
    • Healing trauma and reconnecting: Unmasking the impact of dissociation [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why the WHO’s pandemic accord is critical for global health care

      Elizabeth Métraux | Policy

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Applying the new cholesterol guidelines to real life patients
1 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...