Cholesterol guidelines now focus on risks, not numbers

Remember when cholesterol was defined by a simple number? No more. Cholesterol is now defined as a combination of who you are and your lifestyle. As a result, more Americans could be taking medication to lower it, says Jennifer Robinson, MD, MPH, professor of epidemiology in the University of Iowa College of Public Health and internal medicine in the UI Carver College of Medicine.

Robinson served on the expert national panel that reviewed the previous guidelines and came up with the new ones. She notes that the old guidelines focused mainly on lowering patients’ bad LDL cholesterol to a certain number. The new guidelines, announced by the American College of Cardiology (ACC) and the American Heart Association (AHA), focus on patients’ risks of heart attack and stroke. The new guidelines target four high-risk groups:

  • People who have had heart attacks, other heart disease, strokes, or artery blockages
  • People with genetically high cholesterol levels
  • People with diabetes
  • People at high risk for heart disease and stroke

For these high-risk groups, doctors are advising statins—medications that block the liver from making too much cholesterol. Robinson estimates that about 32 million Americans fit into one of these four groups, but only half of those with heart disease and diabetes are currently taking statins.

“The new guidelines could increase doses for people requiring statins, as well as the overall number of people taking them,” Robinson says. In addition to the new guidelines, the ACC and AHA developed an online risk calculator to help doctors determine if patients might benefit from statins. Age, sex, race, blood pressure, and smoking status are taken into account. Experts like Robinson hope these changes will foster discussions between doctors and patients and lead to better results.

More on the New Guidelines and Their Controversies

The previous guidelines were established 10 years ago based on a limited number of clinical trials, according to Robinson. Since then, she says, researchers have conducted dozens more trials and offered up additional evidence for how to reduce heart attacks and strokes.

“We did a state of the art review, and we came up with a different conclusion,” Robinson says. “And we are excited that this is based on strong science. There is no guessing here. There is a huge amount of evidence.”

Robinson said evidence backing the recommendations is so solid that the committee also can say with confidence that benefits of the drugs outweigh the risks for four categories of at-risk individuals.

“Even if we pick the worst-case scenario of how safe statins are…they still had a large net benefit in the four high-risk groups,” Robinson says. “The benefit from reducing the chance of a heart attack or stroke outweighs any chance for harm.”

Practitioners also now are being advised to re-evaluate dosing in some cases – perhaps increasing it above what would have been recommended in the past. “It’s the dosing and risk factors that matter,” Robinson says.

If Americans were treated according to the new recommendations, about five million more would be candidates for statin treatment, according to Robinson.

“What is important is that we will treat those who are likely to benefit and avoid treating those who are less likely to benefit,” she says.

Robinson says practitioners might have preferred to treat more people in the past, but the medication was too expensive. That is not the case today, as patents on most statins have expired and inexpensive generic versions are available.

“The cost is not an issue any more,” she says. “So let’s have a different conversation about trying to prevent heart attacks and strokes in Americans.”

Some practitioners and field experts have expressed concern about the new guidelines, saying they are confusing and too different from the previous number-centered cholesterol advice. Robinson acknowledged that challenge, but said she thinks the committee managed to streamline the recommendations.

“We tried to make it as simple as possible – even simpler and easier for doctors and patients to understand,” she says.

The panel still stresses a healthy diet and exercise as key in avoiding heart problems. And, officials said, research will continue and the guidelines will be updated again.

“Some data suggests that we might not need to treat people their whole lives with statin,” Robinson says. “But that is an area for future research.”

 –Winter 2013-14