Dr. Patricia Yarberry Allen is a collaborative physician. This week, she asks cardiologist Timothy C. Dutta for a primer on the new cholesterol guidelines, which have generated both criticism and support since they were issued last month.

 

cholesterol

Dear Dr. Pat:

I am 52 and in good general health, except that I am 30 pounds overweight and have high cholesterol. I exercise almost daily, my blood pressure is normal, and no one had a heart attack or stroke in my family until very old age. My parents and their brothers and sisters all had high cholesterol and did not take any drugs to lower it.

About two years ago, my GP told me that I needed to take a statin to lower my cholesterol. My total cholesterol was quite a bit above the recommended range of 200 (mine is 260), and the bad cholesterol was 130. My triglycerides are normal. I read that there are new guidelines for treating cholesterol with statins. I hate taking drugs, and wonder if these new guidelines would indicate that I don’t need this drug anymore.

Rebecca

 

Dr. Pat Responds:

Dear Rebecca:

You may indeed have a genetic reason to have high cholesterol. We see families where there is no significant pattern of cardiovascular disease but there is documented elevated cholesterol in most family members. Cholesterol-lowering drugs like statins have been a cornerstone of preventive treatment for some time, since heart disease is the number one cause of death for women. However, we have used other drugs in the past to “prevent heart disease” like Hormone Replacement Therapy, only to find after careful study that the Hormone Replacement Therapy increased the risk of heart attack and stroke.

Until the experts figure out what the new guidelines actually mean, I would suggest that you do four things that are well documented to lower your risk of heart disease:

• Lose the weight.

• Continue to exercise vigorously as often as possible.

• Choose a diet that is heart healthy.

• Add meditation to your life, even if only for a few minutes a day.

Dr. Pat Allen

 

Dr. Dutta on the New Guidelines:

Dear Rebecca:

It has now been about one month since the new cholesterol treatment guidelines were released, and there continues to be controversy about the guidelines. The 2013 guidelines were generated jointly by the American Heart Association (AHA) and the American College of Cardiology (ACC). They come nine years after the last guidelines were published, in 2004. Already many respected experts have offered their opinions in major journals—giving support, criticism, and sometimes both. The commentary has not been slowing down: Just last week, the American College of Endocrinology weighed in, stating that the new cardiology guidelines are not in line with their society’s guidelines.

Controversies generated by the guidelines involve the decreased emphasis on lipid-lowering targets and a greater tilt toward statins, away from other cholesterol medications, both as alternative treatment or as add-on treatment. The biggest controversy is a risk calculator for patients for primary prevention. “Primary prevention” refers to patients who have not yet had a heart attack or other vascular event, and there has long been controversy about who should take a statin.

For these patients, the guidelines use a new risk calculator to estimate the 10-year risk of a heart attack. If the risk is greater than 7.5%, then a statin is recommended. A major controversy has developed over the risk calculator.  Is the new calculator overestimating risk and putting more people on statins than necessary? Is it underestimating risk and not putting enough people at risk on statins? Is it putting the wrong patients on statins?  The new risk calculator really is new, and has not been previously published or openly validated before. There is disagreement among reputable experts as to how well it works, and simulations of the calculator indicate that it may not be accurate.

Approximately 10 percent of the population in the United States takes a statin, so cholesterol is one of the most important topics in preventive medicine.  Many of us wish these issues had been vetted before the guidelines were published, but they are certainly being vetted now. It is too premature to say if the new risk calculator will hold up or need to be modified. I do believe that in time, the process will advance and help doctors and patients make better decisions about using cholesterol medication.

 

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  • Diane Dettmann December 23, 2013 at 9:31 am

    A few years ago my doctor connected me with a dietary coach who helped me get on track with a healthy diet and daily exercise. I’ve maintained a healthy weight since and my numbers have improved tremendously. Sometimes I get tired of all the salads we consume and think about skipping my daily walk-run, but now that the routine is part of my life, I just “do it”. Thanks, Dr. Pat, for the helpful, timely post!

    Reply
  • Roz Warren December 23, 2013 at 8:45 am

    Great post. My doc has suggested that I take a statin, but I have three concerns.
    l) Has their impact on women, as opposed to men, been thoroughly studied?
    2) Do they actually have any impact on longevity?
    3) What are the side effects of taking them over a long period of time?
    I don’t think any of these questions can be answered with any certainty at this point, so for the time being I’m maintaining a healthy weight, getting lots of exercise and eating a healthy diet. But meditation? Really? I guess if Dr. Pat says so, I’m going to have to try it. Any recommendations for how to go about it?

    Reply