What's up with statins?
By Peter Oettgen, MD
If you’ve been following the media coverage of the new guidelines for the use of statins to lower cholesterol, you may be confused.
First, the country’s top heart organizations issued sweeping new guidelines, including an online risk calculator designed to help physicians determine risks and treatment alternatives. The new guidelines suggest the number of adults who would benefit from the cholesterol-lowering drugs is significantly increased.
Then, a few days later, two renowned Brigham and Women’s Hospital researchers strongly and publicly questioned the validity of the risk calculator, saying it seems to overestimate people’s risks of having a heart attack or stroke and could result in many millions more going on the drugs than need to.
What’s going on here? Can’t the experts get their stories straight?
This kind of disagreement in academic medicine can happen, particularly after new guidelines are released. In time, after further discussion and review, it will all be straightened out. In the meantime, physicians treating patients will continue to use their best judgment in recommending statins. They may use the tool on a trial basis, but not as a substitute for their own judgment. At least, that’s what I intend to do for now.
The recommendations are guidelines, not mandates. If a physician feels strongly that the guidelines don’t fit a patient, he or she does not have to use them.
There is a chance that the risk calculator may be adjusted over time after more discussion and after physicians have experience using the tool. Practices will not change immediately. In the end, the process will lead to improvements in how we assess risk and make treatment decisions.
The new formula for determining who should take statins is intended to help us physicians calculate the chances of heart attack and stroke in patients, particularly those in certain risk categories.
This is a change from the way it has been done for years -- focusing mostly on a person’s level of LDL or “bad” cholesterol. The new guidelines encourage physicians to consider age, weight, blood pressure and other factors such as smoking and diabetes.
The treatment guide urges physicians to prescribe statins for patients between ages 40 and 75 whose 10-year-risk of having a heart attack or stroke based on the calculator is 7.5 percent or more. Statins may be prescribed even if a person’s LDL cholesterol is low.
Doctors are still advised to use statins to prevent heart disease deaths in people who have diabetes or who have had a previous heart attack or stroke.
The Brigham and Women’s researchers who questioned the tool said it over-predicts risk by 75 to 150 percent. This could lead to overprescribing the drugs.
At the same time, the guidelines do not say what to do with patients who fall under the 7.5 percent risk. The implication is that they do not need to be treated, but many of us would disagree. I believe the calculator might miss certain patients that might warrant treatment.
There are cases where our clinical judgment has to come into play. For example, the calculator does not include family history. In many cases, family history should be considered in the decision on whether to prescribe a statin.
Also, the calculator does not make recommendations based on lifetime risk of heart attack or stroke. Somebody could have a lifetime risk of 50 percent but because he is younger, the 10-year risk might be under 7.5 percent.
I do believe a lot of thought and time went into developing the guidelines and that the goals are good. In the meantime, the executive chairman of the guideline committee said the organizations that published the guidelines -- the American Heart Association and the American College of Cardiology -- would examine possible flaws in the calculator and determine if changes are needed.
Until then, I will discuss the issue with my patients and continue to use my best clinical judgment in determining who should take statins and who should not, since I have always considered other factors besides LDL cholesterol, including smoking, blood pressure and diabetes. This is what most clinicians do. I will also use the calculator on a trial basis, but not as a substitute for my standard clinical judgment. It is my guess that most physicians will wait a few months before using the calculator to see what happens in terms of any adjustments that might be made.
Dr. Peter Oettgen is Director of Preventative Cardiology at Beth Israel Deaconess Medical Center.