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Weighing new cholesterol treatment guidelines

ramo12-25-11ALBUQUERQUE, N.M. — In November 2013, the American Heart Association/American College of Cardiology released guidelines labeled “The Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults.” The guidelines outline when medication should and should not be used to treat an individual’s serum cholesterol levels.

The new guidelines are strongly based on randomized clinical trials, whereas in the past, the recommendations derived in large part from expert opinion not always supported by such clinical trials. Now the goal is to treat an individual’s risk for developing coronary artery disease with problems like heart attacks, coronary angioplasty or bypass surgery. Plus, now for the first time the risk of stroke is considered.

The guidelines emphasize that before drug therapy for cholesterol, you try to achieve ideal body weight, exercise regularly and control your blood pressure. If your risk still indicates you would benefit from drug treatment, the guidelines offer advice on how to do that.

When you have a lipid panel, it measures HDL and LDL cholesterol and triglyceride levels. The HDL cholesterol, the good or “Happy” cholesterol, removes the cholesterol from cells in the plaque in the coronary artery and is protective against heart attacks. To date, medication to treat HDL cholesterol has failed to change a person’s outcome as defined by lowering risk for a stroke, heart attack or cardiac death. So, we do not recommend supplements like niacin or omega-3 fatty acids or newer drugs called cholesterol ester transferase inhibitors for that purpose.

Triglycerides are not treated with medication as lowering them with drugs does not change outcomes either. Triglycerides that are very high can cause pancreatitis and levels exceeded 1,000 are treated. So, if you take Lopid or Tricor or any drug for high triglycerides, you likely do not need it. Both HDL and triglycerides are treated best with a carbohydrate-restricted diet and weight loss.

Treating with statins to lower LDL cholesterol will reduce the risk for stroke and heart attacks and keep you alive longer. Reducing your LDL with Zetia or fish oil makes the numbers better but has no effect on outcomes.

To determine if you are a candidate for statins based on the new guidelines see if you fall into one of the following three categories:

1. SECONDARY PREVENTION: Individuals who have had a stroke or have known coronary artery disease should take statins. That includes people who have had a heart attack, coronary bypass, angioplasty or a stroke. Diabetics should be treated with statins. The new guidelines now recommend that doctors specifically prescribe the most powerful statins — atorvastatin or rosuvastatin — in high doses. Instead of shooting for a target level, the guidelines say just take the drugs.

2. PRIMARY PREVENTION (never had a cardiac event or stroke): Statins are recommended for individuals over 21 who have LDL cholesterol above 190. The threshold for treatment is much higher than advised in previous guidelines.

3. PRIMARY PREVENTION in people with LDL between 80 and 189: This will be the largest group and likely that is you. Statins are advised when your risk for a coronary event or stroke is more than 7.5 percent over the next 10 years. So low-risk people can avoid statins even though their LDL is 165 if their risk is calculated to be below 7.5 percent/10 years.

You might think this risk calculator would eliminate a lot of people but it does just the opposite, primarily because age is the most powerful factor in the calculator (clincalc.com/Cardiology/ ASCVD/PooledCohort. aspx). The calculator considers gender, age, race, total cholesterol, HDL cholesterol, blood pressure, diabetes and whether an individual is currently a smoker. It does not consider the family cardiovascular disease history, triglycerides, waist circumference, body-mass index (BMI), lifestyle habits and past smoking history.

The calculator overestimates an individual’s risk. Using the calculator, half of white males over 50 and nearly 100 percent over 70 would be advised to take a statin even though they have no history of heart disease or a stroke. The vast majority of African-American women in their 60s would, too, along with one-third of white women. Overall, the new guidelines would increase the current number of people taking statins from 35 million to 70 million people.

Because of what I consider to be a flawed risk calculator, I believe there will be a modification to include the other risk elements because I do not believe patients or doctors will go along with the currently constituted risk estimate.

As a consumer, you need to know how much benefit you receive from taking a statin and decide if it is worth it. For example, if you are in group 3 and your 10-year risk is above 7.5 percent, you will cut your risk of having a stroke or coronary heart event from 1.8 percent per year without a statin to 1.4 percent (22 percent reduction) if you took a statin. People in group 1 would see their risk fall from 5.6 percent to 4.6 percent and with Type 2 diabetes, the risk falls from 5 percent to 4 percent per year.

So the guidelines say do not treat your numbers, treat your risk and if you treat the LDL cholesterol use statins. If one statin causes side effects try another one. Bear in mind, these guidelines are just that and every person has to assess the risk of the statin vs. the benefits.

Clearly, you will have to discuss your risk with your doctor and decide if the benefits are sufficient to justify taking a statin drug that will take for the rest of your life.

Dr. Barry Ramo is a cardiologist with the New Mexico Heart Institute and medical editor for KOAT-TV. Send questions for him to Albuquerque Journal Live Well, P.O. Drawer J, Albuquerque, NM 87103, or email them to htaylor@abqjournal.com.

Spotlight on Health

Dr. Barry Ramo hosts the second of a three-part series on health and wellness at 7:30 p.m. March 5 at the KiMo Theatre, 423 Central NW. Topic is heart health. Admission is $5 for adults; $3 for seniors, students and children. Tickets available at the box office, kimotickets. com or call 768-3544. Third installment is April 2 on diabetes.

 

 

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