DocSwiner's Superwoman Complex Blog

What better way to celebrate February, heart healthy month, than by thinking about prevention of heart disease. In light of this, I decided to review the brand new recommendations on screening and treatment of patients with high cholesterol. It came out last November, written by the American College of Cardiology and American Heart Association. 

What it reviews and recommends is slightly different and a bit more complicated than our usual way of thinking about treating cholesterol. Generally speaking, patients with a total cholesterol of more than 200 or LDL cholesterol of more than 130 were considered at high risk for artery or heart disease. Before, if diet and exercise didn’t bring numbers down, medications were usually the next step. This was thought to be the case for almost anyone of adult age, not necessarily children, especially if there was a positive family history of heart attack or stroke, or similar cardiovascular issues.

However, after reviewing the new guidelines, here’s my new understanding of how I will approach my patients from now on.

No longer will I primarily focus on just the numbers. Now, let me start by saying I almost never just “treated the numbers” and not consider the person in front of me. Medications aren’t for everyone – some people will outright refuse them, some will beg for a chance to make improvements naturally, and others have medication allergies and can’t tolerate them.

However, in the past, I would use the numbers to help motivate a patient to change his bad habits to avoid medicines. If any patient walked in with a total cholesterol of more than 200, especially someone in his 40s or 50s, cholesterol medicines would have been definitely considered. But the new guidelines for cholesterol put much more weight on the future risk of “atherosclerotic” (artery disease and plaque) and heart disease, and help you to calculate a person’s risk of having problems in the future instead of just focusing on one factor alone.

We can now estimate a person’s risk by using “calculators” that were created with research studies. I’ve used one for a while now called the Framingham Risk Calculator that takes age, gender, blood pressure and smoking history into account. It can estimate a person’s 10-year risk of having a heart attack. 

If one’s risk is greater than 20 percent, it’s a sign that he may need medicines to treat his blood pressure and cholesterol, or need further testing of the heart. I would use this generally to estimate whether I needed to send patients to have a stress test or not if they were having chest pain. If their risk was low, I would consider less emergent causes such as muscle pain, acid reflux or even emotional stress. 

A newer calculator used for cholesterol and heart disease is called the 10-year ASCVD risk calculator, and it takes into account similar history factors (along with race and history of diabetes) as the other calculator, but also estimates risk of stroke and coronary heart disease death, along with heart attack. If risk is >7.5 percent with this, it is important to treat a patient for his cholesterol with diet, exercise, lifestyle changes and, when necessary, medicine.

The medicine of choice is still a statin, which you may recognize as Lipitor, Zocor or Crestor. Each in their generic form end with the word “-statin”, which helps to pick them out from the rest. The study has shown these medicines still work the best for controlling cholesterol and are better than the others we’ve used as alternatives. This part is a little disheartening, given I have many patients that are on Niacin, fish oil or krill oil nowadays, in hopes that this will help lower cholesterol. From this study’s standpoint, they may not match up to the power of the statin.

All in all, here’s the breakdown of which patients benefit from being on statins for cholesterol:

1. All patients with history of heart attack, stroke, TIA or artery disease 

2. Patients with LDL-cholesterol > or equal to 190, regardless of age

3. Patients age 40-75 with diabetes, having LDL 70-189

4. Patients without heart disease or diabetes, but have LDL 70-189, with 10-year ASCVD future risk >7.5%

Let’s all focus on trying to be healthier this year and have our annual checkups with blood work for prevention of disease.

References:

2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults