Change of Heart? Patients to Make Cholesterol Decisions on Risk and Not Numbers
The latest guidelines from the American Heart Association and the American College of Cardiology finally focus on what is really important in regard to heart health: risk. Currently, the guidelines have pushed providers and patients alike to focus almost singularly the cholesterol number. One downside of this unfortunate focus has led to physicians being given bonuses or higher levels of reimbursements for achieving certain defined (but not truly evidence-based) cholesterol number lowering, yet their patients' risk does not necessarily improve. In fact, with the mounting risks of statin therapies, from dementia to diabetes, maybe we've even done folks a disservice.
I applaud these associations for helping us leave the numbers game out of the singular focus for determining therapies. Instead the new guidelines point providers and patients to do a calculation and have a discussion of risk. They advise using the cholesterol data, along with age, blood pressure and other risk factors to help patients understand what their true risk of event is. They are creating a new calculator to help determine what this risk is. I've been using the Framingham risk calculator from the National Heart, Lung and Blood Institute with patients to help them better understand their personal risk and I suspect the new calculator will be much the same. Their advice is that if the risk is greater than 7.5% than the side effects of statin therapy is often worth accepting to lower event risk. I am not convinced this number should be set in stone, but rather each patient treated as an individual in regard to whether or not they feel the risk is worth it.
I frequently get patients coming to see me to either get off of statin drugs and/or seek an alternative to starting them, knowing and concerned about side effects. Inevitably the discussion leads to discussing what their true risk of cardiovascular event (heart attack and/or stroke). How can you make a decision on whether or not to risk the side effects of medication, if you don't have an event risk to weigh this against? Most patients are simply told to take the statin because their cholesterol is outside of some predetermined range. Even worse, many are advised to take statins based on their total cholesterol (which includes in the sum the good, HDL cholesterol) rather than their LDL.
The other important aspect of the guidelines is that when it is determined by provider and patient (IMPORTANT NOTE: the decision is always the patient's, not the providers!) that therapy to lower risk is advisable, the choice of therapy should be more focused on evidence-based medications like the statin class. I actually agree with this. Medications like Zetia and Vytorin are still big time sellers, and there's actually a new one coming soon, do nothing to additionally to lower risk and should not be considered.
Are there side effects of statins? Yes. But remember we are talking about cases when the risk of doing nothing is outweighed by the risk of side effects. Also realize that when statins are an option, that also makes red yeast rice, a natural alternative to statins that has stood up in the evidence, an advisable option as well. Just make sure to choose a pharmaceutical-grade option that is free of citrinin.
The choice of statin/red yeast rice is based on the fact that these agents also target inflammation, and this actually may be a much more significant reason for considering them than the cholesterol reason. The JUPITER trial from 2008 showed that using a statin and focusing more on hsCRP (a marker of inflammation) rather than cholesterol will lower CV event risk.
I applaude the AHA and ACC for making this dramatic shift in guidelines. It's an exciting step in the New Medicine Revolution, the one where patients are their own best doctors and advocates, and we as physicians should spend our time helping them make their own best decisions for optimal well-being and true prevention. Now we just need to redirect the reimbursement system away from rewarding doctors for merely lowering a cholesterol number, and inspire focus on working with patients in lowering risk of event and optimizing quality of life.
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