Most of us know that high cholesterol can raise our risk of heart disease or stroke—and about a quarter of us, according to the Centers for Disease Control, are keeping our cholesterol in check by taking statins, drugs that reduce fat in the blood.
But that number may soon rise. The American Heart Association and the American College of Cardiology have written new guidelines for preventing heart attack and stroke, including new cholesterol medication guidelines, the first revision since 2002. The new treatment guidelines could as much as double the amount of individuals who take cholesterol-lowering medication.
“The guidelines panel created evidence-based guidelines to answer the question for adults, ‘How do I reduce my risk of heart attack and stroke?’” says the panel’s chair Neil J. Stone, MD, the Robert Bonow, MD Professor in Medicine-Cardiology at Northwestern University Feinburg School of Medicine in Chicago.
The new guidelines indicate four groups that may benefit most from statins:
- Adults who have already had a heart attack or stroke;
- Adults with an LDL, or bad cholesterol, of 190 or higher;
- Adults 40 to 75 years old with diabetes;
- Adults whose doctor determines they have at least a 7.5 percent risk of heart attack and stroke within the next 10 years. But a 7.5 percent risk doesn’t automatically mean a person will take a statin, says Stone: “The guidelines insist on a ‘risk discussion’ between patient and clinician.” The doctor and patient weigh potential benefits, possible adverse effects, and the patient’s preferences—and only then decide whether the patient should take a statin.
The New, More Inclusive Risk Calculator
Your doctor’s assessment and a blood test determine your percent of risk. The factors your doctor tallies include race, gender, age, total cholesterol, HDL (good cholesterol), blood pressure, use of blood pressure medications, diabetes and smoking status–a broader assessment than previous guidelines called for.
“The importance of the new risk calculator is that for the first time it assesses risk for heart attack and stroke, not just heart attack,” says Stone. That’s particularly important for women and African Americans, who are more liable to suffer strokes than heart attacks. “If we only look at heart attacks, that would take a lot of their risk out of the equation,” says Stone.
According to the American Heart Association, African Americans have twice the risk of a first-time stroke compared to white individuals. About 425,000 women a year have a stroke, approximately 55,000 more than men, says the National Stroke Association.
If a person is still unsure about whether to take statins despite the new calculator—say, in patients under age 40—several factors may shape her decision: a family history of premature heart attacks and stroke before age 55 in men and age 65 in women; and an LDL of 160 or more. “Such people could be at high risk,” says Stone. “Our guidelines allow them to be treated. But the new guidelines couldn’t elaborate on every single instance. Care has to be personalized, and that’s what makes the new guidelines special: Everyone should have their risk determined. And in lower risk patients, the decision to take statins is between them and their doctor.”
A Change in Targeting Bad Cholesterol
Former guidelines suggested that LDL levels should be less than 100 mg/dl for heart disease patients, or less than 70 mg/dl generally. Now, the guidelines suggest that doctors look at overall risk rather than an LDL number alone. “LDL levels are not less important,” says Stone. “The higher the LDL level the greater the risk. But the panel couldn’t find evidence that targeting a specific number makes a big difference. What’s important is to target the therapy that works, and statins have the best evidence to support their use.”
Some patients may take drugs other than statins such as niacin, which raises good cholesterol, or combine an alternative drug with a lower dose of statins, particularly if a patient can’t tolerate statins. “However, these alternatives shouldn’t be considered in most cases,” says Stone.
Not a Statin Stampede
Although some reports have said that the new guidelines could double the number of people on statins, that’s just not true, says Stone. The former guidelines looked only at heart attack risk. Including stroke risk naturally raises the number of people whom statins should protect—and might have doubled it except that doctors have been treating patients with statins more aggressively than the former guidelines called for. “So our guidelines should not raise the number of people taking statins more than five to 10 percent, if it is raised at all,” says Stone. And the guidelines better ensure that patients who most need statins will be taking them.
Statins carry a small risk of diabetes and muscle pain. “Like all medicines, you have to consider the benefits and risks with your doctor,” says Stone.
Amending Bad Habits
The new guidelines also emphasize that people should work on heart attack and stroke prevention through the way they live:
- Eat a heart-healthy diet high in vegetables, fruits, whole grains, low-fat proteins like fish and chicken, and low in saturated and trans fat.
- Lose weight. A body-mass index (BMI) below 25 is considered healthy. To figure your BMI, go to the American Heart Association website, http://www.heart.org.
- Cut salt to a teaspoon a day, with a goal of eventually cutting that almost in half. Salt causes your body to retain water, raising blood pressure, which can lead to heart disease.
- Exercise briskly for 40 minutes three to four times a week.
- Quit smoking.