Dr. Jacqueline Gerhart: New Guidelines Aim To Prevent Heart Disease
Madison, Wisconsin - UW Health Family Medicine physician Jacqueline Gerhart writes a column that usually appears weekly on madison.com and in the Wisconsin State Journal. Columns are re-published here with permission.
Dear Dr. Gerhart: My doctor wants me to start taking a cholesterol medication, but my cholesterol hasn't gone up recently. Did something change?
Dear Reader: This was probably your first visit to your doctor since the new cholesterol guidelines came out from the American College of Cardiology and the American Heart Association.
In the past, we checked your cholesterol levels every year, with the goal of having your "bad" cholesterol (LDL cholesterol) less than 130. For people over the level of 130, we often recommended they start cholesterol medications called "statins." Statin medications work by reducing the production of cholesterol in the liver – which in turn lowers the cholesterol levels in your blood. When a patient starts a statin, we usually see their LDL cholesterol level decrease.
Until now, the LDL level was the main thing we used to determine if someone should be on a statin. However, the new guidelines now recommend that anyone with known heart disease or diabetes – regardless of their blood cholesterol levels – should be placed on a statin. The new guidelines also include a new calculator for estimating the risk of a major cardiac event, such as a heart attack. This calculator uses a patient's age, smoking history, blood pressure, family history and cholesterol levels to determine a patient's percentage risk of a cardiac event in the next 10 years. In general, a risk of 7.5 percent or higher should be treated with a statin.
So why do we care about your lowering your cholesterol now when we didn't before? Essentially, we are trying to prevent problems before they happen. We know that cholesterol can build up in your heart and blood vessels, leading to heart attack, stroke and peripheral vascular disease. It is one of the major risk factors for heart disease, which is one of the leading causes of death and disability in the U.S. The new guidelines aim to prevent patients with a high risk of cardiac disease from developing high cholesterol in the first place.
These changes do not come without controversy. Some physicians feel that the calculator overestimates risk – thereby putting too many people on a statin. Under the new guidelines, almost half of all Americans over 40 would be candidates for statin therapy. This is an increase of 13 million people. Most of those patients would not have underlying heart disease or high cholesterol but would be counseled to start a statin due to their calculated risk of heart disease. This represents billions of dollars in drug therapy targeting prevention and disease risk, not targeting high cholesterol itself. And, as the number of patients taking statins increases with these guidelines, the number of patients affected by side effects increases concordantly. Specifically, statins can cause muscle pain, increased risk of diabetes and kidney and liver problems.
One benefit of these new changes is that instead of targeting a number, we are now focused on having a conversation with you about your personal cardiac risk. While the guidelines may state to start a statin based on your risk factors, we will also point out ways to change your lifestyle to decrease your risk of heart disease. Sometimes it only takes quitting smoking, eating healthier or following a regular exercise regimen to lower your risk. And those changes can cause you to no longer need cholesterol medication!
I would like to thank Adam Sheka, third-year medical student at the UW School of Medicine and Public Health, for his collaboration on this article.
This column provides general health information and is not specific advice intended for any particular individual(s). It is not a professional medical opinion or a diagnosis. Always consult your personal health care provider about your concerns. No ongoing relationship of any sort (including but not limited to any form of professional relationship) is implied or offered by Dr. Gerhart to people submitting questions.
Date Published: 06/18/2014