Steven Nissen, MD, discusses the controversy in the world of heart disease prevention that may affect millions of people: the one-third of all American adults who have increased risk of heart attack and stroke.
In early November important new guidelines on cholesterol-lowering statin use were released. I responded favorably about this development.
The key aspect of the guidelines developed by the American Heart Association and American College of Cardiology was the identification of patients who were still healthy, but who had an increased risk of developing heart disease.
Calculator becomes center of controversy
These guidelines provided a new online risk calculator to determine which otherwise healthy patients should be treated with statins to prevent heart attack and stroke. The number of patients identified using this calculator could effectively add millions more people who could be prescribed statins — a huge shift from the prior guidelines.
After the online heart risk calculator became accessible, I and other doctors raised an alarm that the calculator may overestimate risk. Some authorities, including me, now suggest that the calculator needs to be reassessed before the guidelines are implemented.
This has set off lively discussion over how to proceed with the guidelines on how patients should be treated with statins. Overtreatment is never a good idea. So we stressed that more time needs to be taken to evaluate these guidelines.
Target numbers also controversial
Another area of controversy involves the abandonment of target values for LDL (bad) cholesterol for patients requiring treatment. The previous target levels were never based on solid scientific evidence, but were effective in helping doctors and patients achieve goals.
The new guidelines suggest that patients not be concerned about target levels and simply take either a high or moderate dose of statin medication. So patients either take a statin or don’t, based on the level of risk determined using the calculator.
The elimination of goals may be confusing to patients and physicians.
Guidelines still sound overall
For the most part, however, the new guidelines make good sense.
The guidelines still identify at-risk patients who would benefit from statins, including those with:
- Cardiovascular disease, including angina, previous heart attack or stroke or other related condition
- Very high level of LDL (bad) cholesterol (above 190 mg/dL)
- Diabetes, who are between the ages of 40 and 75
There’s no argument that these patients should use statins. The question concerns those who have no history of cardiovascular disease — and in which the new calculator comes into play.
So how do you know if you should take statins?
Guidelines are just that: guidelines. While the medical community sorts this all out, patients should talk with their doctors about their particular heart risks. It’s not all about numbers. Medicine is also an art, and talking is one of the best tools we have.
The most important factors to discuss with your doctor remain the same:
- Cholesterol level
- Blood pressure
- Lifestyle (if you’re a smoker, diet and exercise factors, etc.)
You may need statins and that’s a lifelong commitment. You should know that these medications are safe and very affordable now.
Don’t forget that a heart-healthy lifestyle is important for everyone. For those on the borderline of risk, eating a Mediterranean diet and regular exercise can help keep you healthy. For those who have heart disease or need to take a statin, a heart-healthy diet will help keep you at the lowest dose possible.
Right approach to preventing disease
The guidelines will be revised and improved. Meanwhile, your doctor and you can use information from both the old and new guidelines to figure out your course of treatment.
As far as controversy goes: It’s all about getting it right to prevent heart disease. That’s what we care about.