Thursday, December 19, 2013

New Cholesterol Guidelines

Recent updated guidelines have been released regarding treatment of cholesterol.  Specifically, this statement suggests who should and should not be on cholesterol-lowering statin medication.

There has been a lot of controversy regarding this document.  And, as a cardiologist, I don't necessarily agree with its conclusions.

What's new -- new research?  New studies? No.  This is just a group of experts coming together to give their opinion.

The recommendation that patients with known significant arterial disease -- including anyone who has had a heart attack or stroke -- should receive statins is definitely supported by clinical studies.

But, the guidelines also suggest that many patients who do not have disease should receive statins.  They present a new risk calculator, and if the risk of the patient is greater than 7.5% for a cardiovascular event (heart attack or stroke) that the patient should receive statins.  That would mean millions more patients on statins.

The major problem that I see with the guidelines is the suggestion of statins for primary prevention.  But, the literature on that topic does not suggest a strong benefit.  To prevent one heart attack or stroke over the course of five years, one would have to treat about 150 patients with a statin pill every single day.  So, when looking at a huge population, yes you see a reduction in the number of heart attacks and strokes. But, odds are, if you are one of those 150 people being treated with a statin, there is a 149/150 chance that taking a pill every single day for five years will not prevent any type of event.

Further, there have been meta-analyses, which are studies pooling data from several other studies, that demonstrate that amongst the primary prevention population, there is no reduction in mortality.  In other words, a statin won't prolong your life.

There's a great editorial from John Abramson and Rita Redburg in the New York Times on the new guidelines, similarly skeptical of expanding the use of statins.

So, if you feel good, why should you take a statin, which is a pill that has a decent chance of causing muscle aches and is known to slightly increase the risk of diabetes, has a less than 1% chance of preventing a heart attack or stroke in the next 5 years, and won't prolong your life?  It's a good question.  Can you get the same benefit from improving your lifestyle?

YES!  In fact, lifestyle will give you even more benefit than a statin pill!  Daily cardiovascular exercise for at least 30 minutes, but preferably an hour, will help you feel better, lose weight, drop the cholesterol numbers, and reduce your risk of a heart attack or stroke.  Diet is potent too -- and, a whole-food plant-based diet will make you practically heart-attack-proof.

I'm not a big proponent of statins for primary prevention because the data to support them just isn't that strong.  While the guidelines do support lifestyle, I think that we as a profession and society need to do more to encourage people to be more active, eat better, manage stress, and maintain a healthy weight.  And that is how we will prevent heart attacks and strokes, not by feeding everyone a statin.

2 comments:

tridog said...

Well,
After opening the PDF, I can say whole heartedly say "This is why YOU get paid the big bucks!" You deserve it if only because you have the tenacity to actually read through all of it, and dissect the important from the filler.
I will go placidly like so many other sheep to my cardiologist and trust that he has done his "bathroom reading" for me, and will take the appropriate measures.
BTW, I started reading your blog solely because I had a new onset SVT dx yesterday. Although I work in medicine, physiology/EP is not my strong suit.
Thanks for being so forthright in your writing.

Ted said...

Agree. I have had great results with patients who DO adopt a vegan diet. THAT is the ultimate prescription--not statins. We, as physicians, need to at least convey this message to our patients and give them option--even though only a small minority heed the advice. But not many physicians go THIS far. They are too accustomed to dishing out the prescription meds.