The Big Statin Question
February 1, 2014
Here's how to decide whether you need one...
With so many doctors now clashing over the recently released statin-drug guidelines, it is no wonder that most Americans are left with lots of unanswered questions about their heart health.
Some medical experts say that the new guidelines, which include a controversial online risk calculator, overestimate risk and recommend statin drugs for too many people. Other authorities argue that the new guidelines represent a state-of-the-art upgrade.
What you need now are clear answers, not just claims and counter-claims from medical honchos. To provide some real perspective on the guidelines, Bottom Line/Healthturned to Harlan M. Krumholz, MD, one of the most respected cardiologists in the country and a leading "quality-of-care" researcher. He was not involved in the creation of the new statin guidelines. Four steps that he uses to advise his patients on statins…
STEP 1: Don't ignore cholesterol levels. The most fundamental change in the new guidelines (see below) is that they now suggest the use of statin therapy for certain groups of people—for example, those with existing cardiovascular disease or diabetes—rather than focusing on very specific cholesterol targets when prescribing statins. However, even though targets have been largely abandoned, the guidelines do still indicate that everyone with very high LDL "bad" cholesterol levels should strongly consider taking a statin.
What this means for you: Knowing your cholesterol level is still vital in assessing your risk for cardiovascular disease and whether you would likely benefit from a statin. Therefore, a cholesterol test should be part of your initial evaluation. If you're not put on a statin, you can also retest every five years.
STEP 2: Forget about keeping score. Until now, the generally -accepted goal of cholesterol-lowering drug treatment was to bring LDL below a target level—100 mg/dL to 130 mg/dL for most people…and 70 mg/dL for those at very high risk for heart disease. If cholesterol failed to drop sufficiently, the statin dose was often increased or other drugs were added.
Why the targets? For years, doctors assumed that because higher LDL cholesterol means more risk for heart attack, reducing these levels with medication would mean fewer heart attacks. But research now shows that this isn't necessarily so.
What this means for you: If you start taking a statin, think of the medication not just as a cholesterol--lowering drug, but as a heart-protecting drug, since it will reduce risk regardless of your cholesterol level.
Once you're on a statin, there's no reason to measure your cholesterol levels. It would be useful only if you want to reconsider this decision, which might make sense if you're overweight but then lose weight, start exercising or make other lifestyle changes.
STEP 3: Start with nondrug approaches. By shifting away from cholesterol targets, the new guidelines focus more on other factors affecting heart health.
What this means for you: Before you consider whether to use a statin, talk to your doctor about active steps you can take to reduce your risk with a healthier lifestyle…
- If you smoke, stop!
- Improve your diet by curbing saturated fats…and boosting "good" fats like those in olive oil and nuts.
- Get regular exercise.
- Control your blood pressure. If diet, weight loss, exercise and stress control do not bring your readings below 140/90 mmHg, talk to your doctor about blood pressure medication.
- Lose weight if you need to. Excess body weight not only raises your risk for heart disease but also makes you more vulnerable to diabetes—a major risk factor for heart attack and stroke in its own right.
STEP 4: Remember to think for yourself. At best, guidelines can provide information about your risk of having a heart attack, stroke or dying and suggest strategies to modify it. But remember, the risk calculator provides no more than an estimate of your risk and should be used as only part of your assessment.
What's more, guidelines cannot say whether the benefit of taking medication is worth the risk to you. Statins can have side effects, including muscle damage and increased risk for diabetes.
Important: There's little convincing evidence that the newer cholesterol-lowering drugs, including the higher-priced option ezetimibe (Zetia), are as effective as statins. So don't take them unless you can't use statins because of side effects and until you have had athorough discussion with your doctor.
Also, guidelines don't factor in your feelings about taking a drug simply on the chance—not with a guarantee—that it will make you healthier and perhaps live longer. Given the same facts, one person will choose treatment and another will not, and they can both be right based on their preferences and goals.
What it means for you: Use the guidelines as the starting point for a conversation with your doctor about treatment—not as the answer. Ultimately, the decision is yours.
KEY POINTS OF THE NEW STATIN GUIDELINES
According to new guidelines issued by the American Heart Association and American College of Cardiology, statins are recommended for people who have…
- Cardiovascular disease. This includes those with a history of heart attack, angina, stroke or transient ischemic attack or anyone who has undergone a procedure, such as angioplasty, to widen arteries.
- Extremely high LDL "bad" cholesterol levels (190 mg/dL or above).
- Type 2 diabetes and are ages 40 to 75.
- An estimated 10-year risk for cardiovascular disease of 7.5% or higher, based on the online calculator, and are ages 40 to 75.*
*To access the online risk calculator, go to the American Heart Association Web site,Heart.org . In the Guidelines Resource Center, click on "New Cardiovascular Prevention Guidelines," then "Risk Assessment Tool."
Source: Harlan M. Krumholz, MD, the Harold H. Hines Jr. professor of medicine (cardiology) and professor of investigative medicine and of public health (health policy) at the Yale School of Medicine in New Haven, Connecticut. Dr. Krumholz is also codirector of the Clinical Scholars Program and director of the Yale–New Haven Hospital Center for Outcomes Research and Evaluation
