Heart disease is the leading cause of death in the world; stroke is #2. New recommendations for evaluating and treating patients at risk for heart disease and stroke came out last month from the American Heart Association and the American College of Cardiology. Applying the new recommendations will likely result in thousands of new patients starting “statin” medications traditionally used for lowering cholesterol, in some cases, even when cholesterol levels are normal. However, statin medications have other biochemical effects that benefit the cardiovascular and cerebrovascular systems and help prevent heart attacks and strokes.
The new guidelines recommend the use of a statin medication (e.g. Lipitor, Zocor) in the following cases: 1) Ages 40-75, no known cardiovascular disease, and 7.5 percent or higher 10-year risk based on a calculator available at http://static.heart.org/ahamah/risk/Omnibus_Risk_Estimator.xls; 2) History of cardiovascular disease (e.g. heart attack or stroke), including chest pain (angina); 3) Age 21+ with a high level of bad cholesterol (LDL) greater than 190; and 4) Age 40-75 with Type 1 or 2 diabetes. The risk calculator considers gender, age, race, total and good (HDL) cholesterol, and the presence of cigarette smoking, high blood pressure (hypertension), and/or diabetes. Note that almost all patients with diabetes are included in the guidelines, exempted only by age. The AHA and ACC believe that applying these guidelines can reduce the risk of heart attack or stroke from 30-50 percent.
Let’s consider a hypothetical patient we’ll call “Bob.” Bob is a 51 year old African American male who goes to see his primary care provider (PCP) for his annual physical. He’s seen some commercials on television for the cholesterol medication Lipitor, and he’s heard on the news something about new cholesterol guidelines. Bob’s numbers from his office visit and blood tests reveal the following: Not on any treatment for high blood pressure and the top number (systolic) is 115 (normal); total cholesterol 190 (normal); “good” (HDL) cholesterol 50 (desirable); no diabetes; he does smoke cigarettes. Bob asks, “So what does this mean — should I take cholesterol medicine?” According to the new guidelines, the answer is “yes”. Bob is 40-75, and his 10-year risk of heart attack or stroke is greater than 7.5% (7.7 percent) according to the new calculator referenced above. Even though his cholesterol numbers are good, the studies show that he would benefit from taking statins.
Consider “Mike”. Mike has the same numbers as Bob, but he does not smoke. His 10-year risk is only 4.5% ( less than 7.5 percent), and thus he wouldn’t qualify for treatment with statins under the new guidelines. However, what if his “bad” (LDL) cholesterol is very high at 155, and his father and 2 brothers all had heart attacks under age 50? (These factors are not considered in the new guidelines.) Even though he doesn’t qualify to take statins according to the new guidelines, most providers would consider Mike’s risk high and consider treating his high “bad” cholesterol. Some have already suggested that the risk calculator may be flawed. Only time will tell.
It’s complicated — there are hundreds of possible scenarios depending on age, gender, race, family history, other conditions, and medications taken. It seems everyone, including doctors, wants a calculator or recipe for treating patients. However, it’s usually not that simple. Of course, the best recommendation is to talk with your PCP about your specific situation. Although statins are considered very safe medications, they can have side effects, and some can be serious or even fatal. Ask your provider about the new guidelines. Then decide together what might be the best tailored plan for YOU. Happy Holidays — and watch that cholesterol!
Dr. Fleming is the Medical Director of The Jane Pauley Community Health Center (which is closely affiliated with Community Health Network). Ideas for this column can be e-mailed to Dr. Fleming at AskDrFleming@gmail.com