New guidelines from the American College of Cardiology and American Heart Association would change the way doctors prescribe cholesterol-lowering statin drugs, but not every doctor agrees with the new strategy.
Under the old guidelines, the statin dose depended on how much it took to get a person's blood cholesterol levels into a certain target range.
Under the new guidelines, which were issued last year, once someone qualifies for statin therapy, the dose should be determined by the person's risk of cardiovascular disease and not according to how cholesterol levels respond to treatment.
People in the highest risk group should be placed on the highest statin dose. Someone in the lowest risk group should receive the lowest dose of statins. And for people in-between, the dose of statins should be in-between.
And once people are started on a statin, they’ll keep receiving the starting dose regardless of how their blood cholesterol level responds to treatment.
Even if they don’t have high levels of “bad” LDL cholesterol, they might qualify for statin treatment if the new formula provided by the guidelines indicates that they face a risk of at least 7.5 percent of having a cardiovascular event in the next 10 years.
“I think that initially both patients and physicians had a hard time letting go of LDL cholesterol goals because the targets gave something concrete to aim for," wrote Dr. William B. Borden, a cardiologist at George Washington University in Washington, D.C. in an email.
"The new guidelines jettison those targets and focus on tailoring a risk modification strategy specific to the patient,” he added.
“These recommendations are more evidence based and focus our prevention efforts on what we know the best to work,” said Borden, who supports the changes.
On the other hand, Dr. Scott M. Grundy from the University of Texas, Southwestern Medical Center and VA Medical Center in Dallas, Texas, believes cholesterol levels should still influence management.
Grundy wrote one part of a two-part critique of the guidelines that’s scheduled to appear online in the Journal of the American College of Cardiology.
“The new guidelines suggest when to start statins in patients at risk,” he said by email. “The other perspective offers a broader approach to cholesterol management that revolves around LDL.”
“A lack of cholesterol goals leaves the physician in the dark for setting an individualized statin dose and evaluating the adequacy of the risk reduction from therapy,” Grundy said.
In his critique in the journal, he wrote that the new guidelines don’t tell doctors “how to adjust the guidelines to best fit the patient.”
In the second part of the critique, Dr. Sidney C. Smith, Jr. from the University of North Carolina School of Medicine in Chapel Hill reviews the new guidelines and the research behind them. His conclusion? Guidelines “inform, but do not replace” the doctor’s judgment and experience.
Evidence from research must be combined with the doctor’s judgment and the patient’s preferences, he said.
How patients and their doctors manage cholesterol will depend on the individual patient's risk, their willingness to take statins and how they both read the results of all the studies.
Regardless of what patients and their doctors think about statins, the guidelines and the experts agree: “A heart-healthy lifestyle remains the foundation for preventing (cardiovascular disease) and must be part of all efforts to improve (cardiovascular) risk factors and outcomes.”