By James Beckerman, MD, FACC
The patient looked at me a little curiously.
“So, we don’t care what my cholesterol numbers are anymore? And you still want me to take a statin? I don’t get it.”
He’s not the only one. I have had this discussion dozens of times with patients during the past 6 months, ever since the American Heart Association and American College of Cardiology presented us with updated guidelines for managing heart disease and stroke risks, including cholesterol. The major take away of the new guidelines is that your cholesterol numbers don’t seem to matter as much as was previously emphasized. In case you haven’t yet had the conversation with your own doctor (and you should), I’ll give you a big picture view of what the changes mean.
We know that high LDL (“bad”) cholesterol is linked to a higher risk of future heart attacks and strokes, so for years we have been prescribing various kinds of cholesterol medications to lower LDL. In the meantime, though, we’ve learned more about the different cholesterol medications and more about other risk factors involved in heart disease. The hope is that we can help prevent heart disease in more people by treating people according to their risk, rather than by treating by LDL alone. That’s the major shift of the new guidelines.
What isn’t clear to many patients is why the new guidelines recommend such an increase in statin use. If we follow the new guidelines to a tee, we could be prescribing medication to 13 million more people. As my patients have asked, “Aren’t statins just cholesterol medication?” Turns out, there may be more to statins than just cholesterol control.
Statins may offer some benefit, however small, even in people with no prior history of heart disease. And statins seem to reduce risk in people even if they have conventionally normal cholesterol numbers. So, although statins started out as a cholesterol-lowering medication, they’ve evolved into a risk-lowering medication. The new guidelines suggest that if you are at risk, you should be prescribed a statin – regardless of your specific LDL number.
But before we decide to put statins in the water supply, let’s try to put these new recommendations into perspective. Not everyone is happy with the new guidelines. Some physicians are less comfortable with prescribing medication to seemingly healthy people. They would rather counsel their patients about healthy eating, exercise, and quitting smoking instead of the potential benefits, risks, and side effects of a new prescription. Lifestyle changes – if we stick with them – are more effective than statins in reducing risk in lots of different ways, from heart disease to cancer to dementia. They are the best health investment you can make.
And some patients are frustrated, too. These guidelines have led to a lot of interesting conversations in my office over the past 6 months. Being prescribed an essentially lifelong medication as a healthy person is impactful in many ways, even beyond the monetary cost and concerns about side effects (around 10%) and the increased risk of developing diabetes (around 0.4%). And many of us equate a prescription with being sick, so being prescribed a medication can change the way we view ourselves and our health in general. A prescription can transform a healthy self-image into an unhealthy one, an indirect kind of side effect.
Finally, both physicians and patients have questions about this concept of lowering risk. That’s because the key point in making any treatment decision is not only determining if something is good for you, but also looking into how good it is for you. And when it comes to medications, how bad it could be for you matters, too. Buying two lottery tickets might double your chances of winning the jackpot, but in the end, the two bucks you spend on the extra ticket probably aren’t worth it. Similarly, if your risk of heart disease is pretty low, then a statin, or any medication for that matter, is unlikely to create a meaningful difference in risk for you personally. If your risk is high, that’s another story.
So what does all of this mean for you? It means that it’s time to learn more about your risk. Numbers like LDL, blood pressure, and BMI may all play a role, but your overall cardiovascular risk includes other variables as well, from your genes to your jeans size, from how much time you spend on your feet to how you use your fork. Unfortunately our risk calculators tend not to take our diets and exercise patterns into consideration, but these are critical aspects of your risk profile and shouldn’t be overlooked.
In the end, people are much more than their data points. Risk reduction changes from person to person, depending on individual situations and where you are starting from. Even as we accommodate new treatment guidelines, nothing should ever replace an honest, informed conversation between people and their own doctors. Next time you see your doctor, maybe focus a little less on your numbers, and a little more on your risk.