Will doctors embrace new statin and heart attack prevention guidelines?
For years doctors have been focused on specific cholesterol numbers to help patients prevent initial and recurrent heart attack. New guidelines mean only those at high risk will be recommended to take the drugs. So how will doctors decide who is at high risk?
For years doctors have been focused on specific cholesterol numbers to help patients prevent initial and recurrent heart attack. New guidelines mean only those at high risk will be recommended to take the drugs. So how will doctors decide who is at high risk? More importantly what are physicians already saying about changes?
Dr. Neil Stone of Northwestern University chaired the committee that wrote the new guidelines, which was a collaborative effort between the American Heart Association and the American College of Cardiology.
No more statins to control cholesterol numbers say experts
Instead of looking at cholesterol numbers Stone said physicians should prescribe statins based on who will really benefit the most.
What that means is you may not need your statin unless you've had a heart attack, are diabetic and age 40 to 75, or if your LDL (bad) cholesterol is 190 or higher. In the past anti-cholesterol drugs were recommended for LDL cholesterol 130 or higher, but 70 or lower for anyone who had already had a heart attack.
There are also other risk factors for heart attack your physician will take into consideration. Examples might include strong family history of heart disease or very high triglyceride levels.
One of the biggest changes is for people with diabetes who were always recommended to take a statin drug can cause aching muscle and even muscle damage. Younger diabetics may not need cholesterol lowering medication.
The new recommendations also could mean bigger profits for pharmaceutical companies.
Estimates are that the number of people taking statin drugs could double. The reason is because it isn't about numbers anymore. Instead, the drugs are suggested based on a new algorithm.
For instance, a very recent study shows people who are metabolically healthy are still at risk for heart attack. It could be physicians will recommend more of the anti-cholesterol drugs based on body mass index.
So now, people with no signs of heart disease and without high cholesterol are being targeted for the drugs.
Race, gender, age, high blood pressure and family history are all tools doctors are now being asked to use to determine if a patient needs to take a cholesterol lowering drug.
If your risk for stroke or heart attack within the next 10 years turns out to be 7.5 percent or higher you may be receiving a cholesterol lowing drug recommendation from your doctor.
Why the change?
One reason is that statins don’t really help people reach the cholesterol targets that doctors have been treating for decades. So why keep giving them when they don't work to control numbers? The panel felt an updated algorithm was needed.
Also, even though statin use might increase – depending on how well the guidelines are accepted by physicians – they’re not without side effects. And doctors know that.
Twenty to 30 percent of people who take the drugs suffer from muscle damage. Liver damage is another side-effect of the medications that requires regular blood work and close watching. Some patients have memory problems from cholesterol lowering drugs. All of the side effects might outweigh the benefits of a patient’s 10-year risk of heart attack who falls outside of the new guidelines.
If you have never been diagnosed with heart disease for instance, you could lower your chances of having one by 0.4 percent. But patients who have had heart complications would lower their heart risks a little more than one-percent, as would diabetics.
Dr. Paul Ridker who is a cardiologist at Brigham and Women’s Hospital said “A 55-year-old male smoker with high blood pressure would be deemed at high risk, but he should be told to stop smoking and given blood pressure drugs, not a statin.”
I would agree – but another approach might be if a 55-year old male smoker doesn't make the lifestyle change then maybe a statin drug should be prescribed for cardioprotection. It ends up a patient/physician decision.
But that leads to another expressed concern from doctors that patients will take cholesterol drugs rather than make lifestyle changes. Also without specific cholesterol level goals, would people just start eating whatever they want?
Other heart specialists feel inflammation should be more the focus in determining who is at risk for heart attack and stroke. A simple blood test that measures CRP or C-reactive protein can gauge inflammation in the body and has been suggested as an adjunct for predicting who is at risk for heart disease by Dr. Ridker.
You can lower inflammation in the body by eating anti-inflammatory foods and cooking with herbs and spices like turmeric and rosemary. Omega-3 fatty acids are also important. One of the reasons people take aspirin to prevent stroke and heart attack is because it quells inflammation.
The Mediterranean diet is shown repeatedly to be linked to lower incidence of heart disease for those who focus on the main ingredients in the diet - fish, olive oil; perhaps some red wine.
Dr. Andrew Weil and Dr. Barry Sears of the Zone diet have been proponents of consuming anti-inflammatory foods to keep blood vessels healthy. Dr. Dean Ornish, a pioneer in reversing heart disease also focuses on diet and lifestyle including controlling stress with exercise, diet, yoga and meditation to lower our heart risks.
What else besides drugs is recommended for heart protection?
We also have new guidelines from the same panel on how to lower your LDL cholesterol and stay heart attack and stroke free.
Even if your doctor recommends a statin for you here are other steps you also need to take:
- Restrict your salt intake to 3,600 milligrams (mg)/day (unless you’re told otherwise by your doctor)
- Eat 4 to 5 servings of fruits and vegetables a day and 6 to 8 servings of high fiber grains
- Consume 6 ounces of lean meat a day (fish or poultry)
- Indulge in 4 to 5 servings (about a handful) of nuts or legumes per week
- Limit trans and saturated fat intake and have two to three servings of healthy oils a day (olive, avocado, canola, safflower oils)
- Limit sweets and sugar. (TIP: An excellent choice to satisfy your sweet tooth is a square of dark chocolate)
- Get plenty of physical activity – 40 minutes of moderate to brisk aerobic activity like walking, swimming, jogging or cycling 3 to 4 times a week.
- Limit your red meat
- Eat and drink low-fat dairy products (TIP: Soy and almond milk are excellent substitutes for cow’s milk)
The new guidelines expand who should receive cholesterol lowering drugs known as statins and removes focus from cholesterol numbers. Some physicians are already expressing concern about the changes. We also have nutrition and activity guidelines that the expert panel says should be embraced by any physician concerned about heart attack prevention.
Updated November 13, 2013