New cholesterol drug recommendations spur disagreement

Some docs think new guidelines on statins are excessive

By Tara Bannow / The Bulletin / @tarabannow

After the American Heart Association released its new heart and stroke prevention guidelines last month, including a new risk calculator, Bruce McLellan, like countless doctors across the country, started running the numbers on his patients to see how their treatment regimens might change.

The results were surprising.

The St. Charles Heart Center cardiologist discovered the new recommendations would bump two of his patients currently taking low-intensity statins (cholesterol-lowering medications) to high-intensity statins, a move that would push their low-density lipoproteins (LDL) or “bad cholesterol” close to 10 or 20 mg/dL — levels so off-the-charts low that there isn’t data on their health effects.

To McLellan, that move “seems excessive.” He’s not alone in that assessment.

The guidelines, co-written by the American College of Cardiology, recommend statins be prescribed to patients with a 7.5 percent chance of having a heart attack or stroke within the next 10 years. Previously, the recommendation was for patients with 20 percent chance over the next decade. The updated risk calculator also focuses less on peoples’ LDL levels and more on other factors, such as a history of cardiovascular disease and stroke, age and diabetes.

They have been the subject of tremendous backlash within the medical community in recent weeks from doctors and others who say they would dramatically increase the number of Americans taking statin medications. Some reports have claimed the guidelines would double the number of people taking statins.

Within days of the guidelines’ release, a pair of Harvard doctors published a paper in The Lancet medical journal that said the risk calculator over-estimated peoples’ actual risk of heart attack or stroke by 75 to 150 percent and would thus result in healthy people being prescribed statins that would have no benefit.

The AHA, however, rejects those numbers. Its leaders say the new guidelines won’t significantly impact statin use and, in fact, could decrease it slightly. In 2005, about 35 million Americans were taking statins.

Under the new guidelines, an estimated 32 million people would be prescribed statins, said Marco Di Buono, the AHA’s vice president of science & research. That’s because the previous guidelines focused only on LDL levels, while the new ones take into account a number of different biological markers, he said.

“This is really not about a one-size-fits-all guideline,” Di Buono said. “This is really about ‘Let’s look at your risks specifically and make a judgment.’”

Di Buono said it’s hard to explain why so many people have misunderstood the new guidelines, but said they demonstrate a “paradigm shift” in that they rely more on conversations between physicians about patients than ever before.

“It’s going to take a while before it really gets absorbed and people really start to understand what the details are,” he said.

Statins, which most people take for the rest of their lives once they’ve been prescribed them, can cause muscle pain and damage, liver damage and digestive problems, among other side effects, according to the Mayo Clinic.

Although much of the debate has centered around the increase in statin prescriptions that could result from the guidelines, AHA president Mariell Jessup said more statins wasn’t the goal.

“The goal was to review the evidence,” she said, “and what the authors feel after evaluating the evidence is that there is very strong evidence suggesting that statins reduce the endpoints of death, infarction and stroke.”

Some local doctors say that despite the guidelines, they’re not going to change much about how they practice.

“For myself, I pick and choose old versus new guidelines based on the individual patient,” McLellan said. And he said he’s slightly wary of the shift away from focusing on LDL to measure risk. “It has logic to it, but I think many cardiovascular specialists also believe there is some logic to using numbers, at least in some cases.”

Rick Koch, a cardiologist at Bend Memorial Clinic, said he’s concerned that simply putting people on medications will shift the focus away from diet and exercise, which are fundamental elements of reducing one’s risk of heart attack or stroke. Minimizing the impact of lifestyle changes also shifts control away from the patient, he said.

“I can put you on a pill that’s going to lower your bad cholesterol, but it might not change your weight; it might not change your blood pressure,” he said.

Western medicine in general tends to not focus enough on lifestyle modifications — diet and exercise — that can have significant impacts on peoples’ LDL cholesterol, blood pressure and obesity, Koch said. He said he was disappointed that the AHA’s report says vegan and vegetarian diets do not significantly improve peoples’ health.

“It takes time to work with patients on those lifestyle modifications, coaching,” he said. “We need to focus more on that. It doesn’t cost anything except time.”

The guidelines also urge doctors to regard obesity as a disease rather than a lifestyle issue. Although Koch said that message also could contribute to patients’ feelings of not having as much control over their health, it overall should be “universally applauded.” Obesity affects about 78 million Americans and leads to hypertension, diabetes and high cholesterol, all of which are risk factors for heart disease and stroke, he said.

At the end of the day, McLellan and Koch agreed, the most important thing in all of this is that people have conversations with their doctors, who will be able to gauge other risk factors, such as other health conditions and the safety of statins on a specific person.

The vast majority of those conversations will and should happen in primary care settings rather than with cardiologists, McLellan said. In some cases, that conversation might result in six months to a year of trying out a diet and exercise regimen to see if that eliminates the need for statins, Koch said.

“The guidelines are just that: They’re just guidelines to looking at potential evidence,” he said, “but nothing really can substitute for that discussion with your physician.”

— Reporter: 541-383-0304,

tbannow@bendbulletin.com