HEALTH MATTERS: A look at new cholesterol guidelines

Q. I've been on a medication for years to treat my high cholesterol. My doctor has adjusted the dose to lower my cholesterol to less than 70. Now, I understand that there are new guidelines that change the rules, and there is no longer such a tre...

Joshua Wynne

Q. I've been on a medication for years to treat my high cholesterol. My doctor has adjusted the dose to lower my cholesterol to less than 70. Now, I understand that there are new guidelines that change the rules, and there is no longer such a treatment target. I'm terribly confused!

A. I can understand your confusion. One of the big challenges that we have in medicine is to make recommendations to patients before we have definitive evidence as to what works and what doesn't. We don't want to wait until we are sure of something before we suggest it because that might deprive many patients of essential care.

On the other hand, we don't want to make recommendations based on flimsy evidence. So as a profession, we try to do the best that we can by making recommendations based on prudence, experience and the best available evidence. As new information and research become available, we then modify our recommendations accordingly. That's what has occurred with the new cholesterol guidelines. It turns out that there simply isn't strong clinical evidence that treating to a specific target level of cholesterol (such as a bad cholesterol level of less than 70) really works.

The big change in the new cholesterol guidelines is a shift from a focus on cholesterol levels to an assessment of the patient's risk profile. Four groups of patients have been identified that are at enhanced risk of heart problems and who should profit from treatment with a cholesterol-lowering drug called statin: those with established atherosclerotic heart disease, such as someone who suffered a heart attack or stroke; those with very high cholesterol (bad cholesterol at or above 190); diabetics ages 40 to 75; and otherwise healthy individuals with a 10-year risk of heart disease or stroke that is 7.5 percent or above, meaning that over a 10-year period, 7.5 out of 100 people on average will suffer a heart attack or stroke.

There is nothing particularly new with the first two indications. We've been doing that for years. But the second two recommendations certainly are new and different, and especially the last recommendation may well prompt many people to be treated who were not before. Note that the level of cholesterol is not mentioned in the latter two indications. As long as bad cholesterol is greater than 70, treatment may be indicated.


What does all of this mean to an individual patient? Well, if you are on a statin because you had a prior heart or vascular event or your bad cholesterol is 190 or above, nothing changes -- you still should be on a statin, although the target level for cholesterol reduction may change. If you are a diabetic ages 40 to 75 and not on a statin, see your health care provider. And for everyone else ages 40 to 75, the American Heart Association has made available a risk calculator to estimate your 10-year risk. The risk calculator is available at . If the estimated risk is 7.5 percent or greater, you are a candidate for statin therapy under the new guidelines.

But no sooner had these new guidelines appeared than a major controversy erupted.

It turns out that there is concern that the calculator overestimates risk, and thus suggests that more people need to be treated than warranted by the evidence. So, you are not the only one who is confused!

For now, I suggest you stay the course -- if you are on a statin, stay on the statin. If you are healthy but considering starting statin based on new guidelines, wait for now. But if you have or develop heart or vascular disease or a very high cholesterol level, the evidence is straightforward -- you need to be on a statin. Once the dust settles on this controversy, I'll provide an update in a future column.

But remember, a healthful lifestyle -- following a heart-healthy diet, engaging in regular physical exercise, avoiding tobacco products and keeping weight under control -- forms the foundation of any program to prevent or treat cardiovascular disease!

Wynne is vice president for health affairs at the University of North Dakota, dean of the School of Medicine and Health Sciences, and a professor of medicine. He is a cardiologist by training.

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The content of this column is for informational purposes only and does not substitute for professional medical advice or care. The information provided herein should not be used for diagnosing or treating a health problem or disease. If you have or suspect you may have a health problem, you should consult your health care provider. Never disregard professional medical advice or delay in seeking it because of something you have read in this column.

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