Michael White, professor and department head from the University of Connecticut School of Pharmacy, talks about the new guidelines for cholesterol released last week by the American Heart Association and the American College of Cardiology.
Here are some questions about the guidelines with answers provided by White:
What is a clinical guideline and how does it impact patient care in the country?
Being a primary care provider is very challenging. There is so much information that you need to know and even if all you did was read studies, you still wouldn’t know everything. So major specialty organizations like the American Heart Association and American College of Cardiology bring together the world’s experts and make evidence-based recommendations that primary care providers can then use with confidence.
What are the big things that are changing in this guideline versus previous guidelines?
There are four big changes: Number 1: diet and exercise is paramount. Number 2: Instead of trying to achieve a certain cholesterol number, like an LDL (what is known as bad cholesterol) below 100mg/dL, they now use your baseline LDL and your risk of having a cardiovascular event like a heart attack or stroke over the next 10 years to determine the intensity of therapy you need. They don’t specify the final target LDL level you end up with. Number 3: Statins like Lipitor, Crestor and Zocor are now king and they want you to use doses of these drugs that reduce cholesterol by 30 to 50 percent for those at moderate risk or in doses that reduce cholesterol by over 50 percent in those at higher risk. So they are emphasizing higher intensity statin therapy for most people and to rely less on combination therapy than previously. And Number 4, for people over the age of 75 years, clinicians and patients are told to decide together whether the benefits are worth the risks of starting a statin.
Why are there such big changes in these guidelines?
Many of the recommendations in the previous guideline were made with preliminary studies or by consensus rather than by solidly conducted large clinical trials. Since 2002 there have been many large, multicenter, clinical trials with tens of thousands of patients being treated over several years that found that statins work better than other cholesterol reducers, that higher doses of statins work better than lower doses, but that adding other therapies to high dose statins reduced cholesterol more but provides little to no additional benefits in terms of heart attacks and strokes. However, they understand that many people can tolerate lower doses of statin but might not be able to tolerate the new higher recommended doses due to muscle aches or weakness. In them, combination therapy with a statin and nonstatin together could still be useful.
If you are over 75 years of age, is it OK not to start statins or to stop them?
A 90-year-old with no heart disease might not need to be on an expensive drug that can cause side effects or someone with advanced Alzheimer’s or untreatable cancer don’t need a drug to reduce cholesterol. If you have cardiovascular disease and a reasonable longevity, I would suspect that after a discussion of the benefits and risks that most people will decide to take statins. However, this stops payers like Medicare from penalizing physicians who decide to stop therapy where it is no longer beneficial.