Everything you need to know about the new cholesterol guidelines

By Dr. Hoffman

Last week, we all awoke to a sea-change in the way mainstream medicine approaches the prescribing of cholesterol drugs. It caught many of the "worried well" by surprise. Even most doctors were blind-sided.

Prescriptions for "statin" drugs--like Lipitor, Zocor, Prevachol and Crestor--have soared over the past decade, fueled by clever TV ads and guidelines put out by the American Heart Association and the National Heart, Lung and Blood Institute. Currently, 37 million Americans take these drugs.

But now, the revised guidelines will cast an even wider net. It's estimated that once they're implemented, the number of Americans taking statins could double.

What are the implications for you or a loved one? Should you get on the statin bandwagon, or should you buck the trend? Here's an analysis.

First of all, here's something good about the new guidelines: They actually offer a concession that our single-minded obsession with cholesterol is misguided!

How can that be when statin drugs are designed to lower cholesterol? Heart disease researchers now finally admit that cholesterol levels should not be the sole determinants of who should get aggressive treatment to lower heart disease risk. The previous guidelines were simplistically fixated on levels of the so-called "bad" cholesterol--LDL, or low density lipoprotein.

The unfortunate result has been that some people with high LDL but with low risk were subject to "cholesterol limbo" (how low can you go!); others with seemingly good LDL but other risk factors were missed.

Additionally, the revised guidelines finally discourage over-zealous doctors from tanking patients up on super-high doses of statin drugs to achieve unrealistically low LDL targets. Why? The cardiology establishment has finally had to admit that statins work not so much by lowering cholesterol, but more by acting like expensive super-aspirin: they reduce inflammation that damages artery linings and sets the stage for plaque accumulation.

Thus, a moderate dose of statin drugs confers protection, even if cholesterol levels aren't totally normalized. So far, so good.

But the new guidelines are imprecise and overly broad. They call for four groups of patients to get statins:

1) Anyone who already has documented heart disease
2) Anyone with an LDL over 190
3) All persons ages 40 to 75 with diabetes
4) Anyone with an estimated 10 year risk of a heart attack of 7.5% or greater

How can you determine your 10 year risk for a heart attack? The American Heart Association has created a convenient interactive site with a calculator at www.heart.org/gglRisk/locale/en_US/?gtype=health

Feed in data about your good and bad cholesterol, triglycerides, blood pressure, blood sugar, age, sex, race, height, weight, waist circumference, family history and . . . presto! You are given a score which predicts your risk of a heart attack.

But missing from the sophisticated algorithm are vital determinants of heart disease risk: your diet, your exercise fitness, your actual body fat percentage, your C-reactive protein (a measurement of inflammation thought by some to be an even more important predictor of risk than cholesterol), your insulin levels (better than just blood sugar to ascertain whether you have metabolic syndrome, a prime risk factor for heart disease) or your actual coronary calcium score (a test I often use to determine vulnerability to heart attacks).

Ultimately, if you use the aggressive 7.5% threshold for initiating treatment with statins, you would need to treat hundreds of patients unnecessarily to save just one or two.

And it's not as if cholesterol drugs are innocuous. While the potential for side effects has been minimized, substantial numbers of my patients report muscle aches, fatigue, and memory problems. Serious liver and kidney problems are well-documented, as are erectile dysfunction, depression and insomnia.

Even worse, diabetes has been reported in surprisingly high numbers of patients taking statins--the very condition which propels millions of Americans toward circulatory problems, heart attacks and strokes!

As John Abramson, MD of Harvard Medical School points out in a New York Times op-ed ("Don't Give More Patients Statins" http://www.nytimes.com/2013/11/14/opinion/dont-give-more-patients-statins.html?_r=1&)

"We believe that the new guidelines are not adequately supported by objective data, and that statins should not be recommended for this vastly expanded class of healthy Americans. Instead of converting millions of people into statin customers, we should be focusing on the real factors that undeniably reduce the risk of heart disease: healthy diets, exercise and avoiding smoking. Patients should be skeptical about the guidelines, and have a meaningful dialogue with their doctors about statins, including what the evidence does and does not show, before deciding what is best for them."

Even many mainstream cardiologists are dismayed by the new guidelines. "This was a catastrophic misunderstanding of how you go about this sort of huge change in public policy," said Dr. Steven Nissen, a Cleveland Clinic cardiologist who is a past president of the American College of Cardiology. "There will be a large backlash," according to an article in the Times this week. http://www.nytimes.com/2013/11/26/health/heart-and-stroke-study-hit-by-a-wave-of-criticism.html?ref=health&_r=2&

Among the absurdities of the new guidelines is that virtually all middle-aged black males-regardless of whether they're healthy or not-will instantly become "racially-profiled" into candidacy for statin drugs!

Another of my astute Facebook friends wrote of the self-test via the calculator at www.heart.org : "I looked at the 'calculator' and what stood out like a sore thumb is there is no question for whether the participant is taking a statin drug. My wife's cholesterol issue is genetic and her total went from 280 to 160 with the drug. The calculator now puts her at a 1% risk, where I am at an 8% risk with a total of 200 and 105 BP. This thing does seem rigged!"

Indeed, this is a mess. At the Hoffman Center, we favor natural therapies to curtail cardio risk. While statins occasionally have a place for high-risk patients, we rarely need to use them.

And for once, even the mainstream media (sort of) agrees. The New York Times took the unprecedented step of issuing an editorial "Cholesterol Guidelines Under Attack" http://www.nytimes.com/2013/11/19/opinion/cholesterol-guidelines-under-attack.html?_r=0 and the influential Toronto Globe and Mail chimed in "It's Time to Question the New Guidelines on Cholesterol Drugs" http://www.theglobeandmail.com/life/health-and-fitness/health/its-time-to-question-the-new-guidelines-on-cholesterol-drugs/article15566990/

Now, more than ever, it's imperative that doctors dialogue with their patients about this important issue.