Patients On Statins Won’t Need To Lower Cholesterol Levels Now, Just The Right Dose Will Be Sufficient

United States’ leading heart organizations released new guidelines on Tuesday that will fundamentally reshape the use of cholesterol–lowering statin medicines, which are now prescribed for a quarter of Americans over 40. Patients on statins will no longer need to lower their cholesterol levels to specific numerical targets monitored by regular blood tests, as has been recommended for decades. Simply taking the right dose of a statin will be sufficient, the guidelines say.

The new approach divides people needing treatment into two broad risk categories. Those at high risk because, for example, they have diabetes or have had a heart attack should take a statin except in rare cases. People with extremely high levels of the harmful cholesterol known as LDL – 190 or higher – should also be prescribed statins. In the past, people in these categories would also have been told to get their LDL down to 70, something no longer required. Everyone else should be considered for a statin if his or her risk of a heart attack or stroke in the next 10 years is at least 7.5%. Doctors are advised to use a new risk calculator that factors in blood pressure, age and total cholesterol levels, among other things.

"Now one in four Americans over 40 will be saying, ‘Should I be taking this anymore?’" said Dr Harlan M Krumholz, a cardiologist and professor of medicine at Yale.

FOOD FOR THOUGHT

The new guidelines, formulated by the American Heart Association and the American College of Cardiology and based on a four–year review of the evidence, simplify the current complex, five–step process for evaluating who needs to take statins. In a significant departure, the new method also counts strokes as well as heart attacks in its risk calculations, a step that will probably make some additional people candidates for the drugs.

It is not clear whether more or fewer people will end up taking the drugs under the new guidelines, experts said. Many women and African–Americans, who have a higher–than–average risk of stroke, may find themselves candidates for treatment, but others taking statins only to lower LDL cholesterol to target levels may no longer need them.

The previous guidelines put such a strong emphasis on lowering cholesterol levels by specific amounts that patients who did not hit their target levels just by taking statins often were prescribed additional drugs like Zetia, made by Merck. But the new guidelines say doctors should no longer prescribe those extra medicines because they have never been shown to prevent heart attacks or strokes.

The new guidelines are part of a package of recommendations to reduce the risk of heart attack and stroke that includes moderate exercise and a healthy diet. But its advice on cholesterol is the flash point, arousing the ire of critics who say the authors ignored evidence that did not come from gold–standard clinical trials and should also have counted less rigorous, but compelling, data. For example, Dr Daniel J Rader, the director of the preventive cardiovascular medicine and lipid clinic at the University of Pennsylvania, points to studies of people with genes giving them low LDL levels over a lifetime. Their heart attack rate is greatly reduced, he said, suggesting the benefits of long–term cholesterol reduction.

Committee members counter his view, saying that cholesterol lowered by drugs may not have the same effect.

Critics also question the use of a 10–year risk of heart attack or stroke as the measure for determining who should be treated.