Ask Dr. Pat

Cholesterol Management: Prescription for Lifestyle Change Or Prescription for Medication

 

Dear Carla,

One of the most important messages that I try to convey to my patients when discussing statin therapy is one that Dr.Pat has clearly emphasized. Statin therapy is important and can be helpful in certain patients against a backdrop of aggressive lifestyle modification. Diet, exercise, weight loss and stress reduction remain the cornerstone to decreasing cardiovascular events. Starting a statin drug does not mean that one can make poor food choices and disregard exercise. The statin drug is part of an effective medical regimen but is ineffective by itself.

When a patient seems to be a candidate for statin therapy, I follow the current guidelines and evaluate the patient in terms of this patient’s individual risk for heart disease. In 2013, the American College of Cardiology (ACC) and the American Heart Association (AHA) released new updated guidelines for the treatment of high cholesterol to prevent cardiovascular disease including heart attacks and strokes.

These guidelines help to guide my decision. One of the biggest changes with these guidelines was that cholesterol targets, specifically a numeric goal for the levels of LDL or “bad cholesterol,” were eliminated. The focus of these new guidelines is not specifically treating a number but rather assessing a patient’s entire risk profile and identifying and treating high risk individuals who would clearly benefit from statin therapy.

The updated guidelines from 2013 identified four high risk groups of patients including:

  • People with existing heart disease
  • People with an LDL level of 190 mg/dL or higher
  • People between 40 and 75 years of age who have Type 2 diabetes
  • People between 40 and 75 years of age who have a 10-year risk of heart disease that is 7.5 percent or higher. (**this is based on a risk calculator that was developed by the guidelines committee and described in the guidelines.)

In the first three groups, the patients are categorized as high risk and automatically qualify for a statin. They do not need risk assessment. However, there is much more ambiguity and discussion regarding the fourth group of patients. In this group, there is much more room for the doctor and patient to decide together if a statin should be started. The risk calculator does not consider important factors such as family history and it places an enormous emphasis on age. There are also recent additional guidelines by the US Preventive Services Task Force that state that patients with hypertension, diabetes or smoking — in addition to a 10% risk for heart disease should be started on a statin. A recent study in JAMA found that up to 97 percent of people between the ages of 66 and 90 qualify for statins under the new guidelines with the accompanying risk calculator. Therefore, each case must be closely examined in order to make the right decision for each the patient.

Carla, when you discuss your concerns about medication with your healthcare team, you can be reassured that  there is no clear indication for statin therapy as you have not had a heart attack, you have no diabetes, you are not a smoker and your family history for heart disease is not strong. Your LDL (bad)  cholesterol is 156. When I calculate your 10-year risk of heart disease you have less than a 7.5 percent chance of developing heart disease.  So, based on the guidelines there is no clear indication to begin immediate statin therapy. However, you have multiple risk factors for heart disease including obesity, hyperlipidemia (elevated total cholesterol and LDL) and a family history that is not with a first degree relative with heart disease at a young age (men <55, women <65) but nevertheless heart disease in a first degree relative. You are the ideal patient to be assessed by a cardiologist to determine when statin therapy should be initiated.

There is non-invasive testing that can be performed to better assess your risk for coronary artery disease and the benefit of statin therapy. As a cardiologist, I routinely use a cardiac computed tomography (cardiac CT) to help with the decision regarding whether to recommend statin therapy in patients with moderately elevated cholesterol and intermediate risk. Cardiac CT is a non-invasive test that allows high resolution, three-dimensional visualization of the heart. The two main types of cardiac CT are coronary artery calcium scoring and coronary CT angiography. In coronary calcium scoring, pictures are taken of the heart to look for the presence of calcium deposits in the blood vessels of the coronary arteries. Calcium deposits are a very specific sign of coronary artery disease. Cardiac CT angiography looks specifically for soft plaque in the arteries of the heart and like the presence of coronary calcium plaque, patients with this finding have markedly increased risk for future cardiac events. There have been multiple studies done over the last decade to support the use of statin therapy to decrease the progression of plaque and to decrease cardiovascular events in these patients.

Conversely, a normal cardiac CTA with no calcium or plaque has an excellent prognosis. Another non-invasive test that is easy and safe to perform is a carotid ultrasound, which measures both carotid intima-media thickness and carotid plaque. There have been several large epidemiologic studies that have supported that CIMT and carotid plaque are closely related with other cardiovascular risk factors and are useful to classify subjects deemed to be at intermediate risk for the development of cardiovascular events. Therefore, if there is a substantial plaque burden seen on the carotid test a statin should be strongly considered.

Carla, I hope this is the information you wanted in order to have a meaningful discussion with your GP.  Obviously, you have to modify your lifestyle considerably if you want to avoid a statin medication. You know what you have to do; now it is up to you to make these changes. I believe that if you lost at least 20 pounds,  increased your exercise routine as well as monitored your diet then your cholesterol would markedly improve. If your cholesterol remained elevated after diet and exercise, ask for a referral to a cardiologist for further evaluation which would include a cardiac CT to assess for plaque.  If there is mild or mild to moderate plaque I would encourage starting a statin. If there is no plaque with a calcium score of 0, I would continue to encourage lifestyle modifications.

Dr. Healy

References

1. 2013 ACC/AHA guidelines circulation 2013
2. JAMA 2016; 316 (19) 1977-1979

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