Don't Chase Cholesterol Targets; Know your Risk!
The American College of Cardiology and the American Heart Association just released new cholesterol guidelines to reduce atherosclerotic cardiovascular risk –- and the change from the previous version, last updated in 2004, is profound. Here are three things you need to know about these new guidelines.
First, the guidelines have moved away from achieving target cholesterol levels.
Americans have long been urged to focus on their laboratory numbers. Many people are obsessive about checking their cholesterol levels and pursuing even better numbers. Doctors have been told to focus on these numbers and, in some cases, the quality of their care was assessed by the percentage of their patients with low cholesterol levels.
Those days are over. The new guidelines recognize that for patients who have exhausted lifestyle efforts and are considering drug therapy, the question is not whether a drug makes your lab tests better, but whether it lowers your risk of heart disease and stroke. Studies over the past several years have shown that improving your lab profile with drugs is not equivalent to lowering your heart risks. Drugs have thousands of effects on the body, and a drug’s effect on an individual lab test cannot necessarily predict its overall effect on you.
Importantly, the guidelines still state that cholesterol is important. But the point is that changing your cholesterol level with medications is now accompanied with the appreciation that other effects of the drugs may offset any benefit to reducing cholesterol.
There’s one exception to the numbers rule. People with very high levels of the harmful cholesterol known as LDL still need to worry about targets. The new guidelines set that LDL level at 190 milligrams per deciliter – but the principle is that if people have very high cholesterol levels, then their cardiovascular risk is so high that it is likely that treatment to reduce the levels would offset any risks of the drug treatment.
So, the new guidelines are saying: we should not be chasing the cholesterol levels alone. The “know your number” campaign is no longer consistent with the guidelines, and the days of doctors adding additional medications to get you to some arbitrary cholesterol level should no longer occur.
Second, know your risk.
What is taking the place of cholesterol levels? What should you do now?
The guidelines are now focusing you on your overall risk of heart disease and stroke. They indicate that drug treatment is recommended for people with a high risk — and that more powerful treatments are best for those with the highest risk.
So what they are saying now is: know your risk of heart disease and stroke. They have published an online calculator to help you -– but more important is the general concept that drug treatment with effective medications (those proven to lower risk) should be used in people with the most to gain.
The guidelines do set thresholds for risk, but my view is that these recommendations should not be considered dictums to be followed without question. They say that if your 10-year risk of heart disease and stroke is 7.5 percent or higher, then you should be treated with drugs. However, I believe that only you can determine what constitutes a high enough risk that it is worth it to you to be treated with drugs. Such a decision depends on how you feel about your risk of heart disease and stroke and how you feel about taking drugs — and their risks and benefits.
Third, use medications proven to reduce risk.
The understanding that simply improving cholesterol lab tests may not reduce your risk for heart attack and stroke has focused attention on the choice of drug therapy. In the “treat to target” era, there was a sense that we could use any of the medications to lower LDL — and what was most important was the lab test.
However, there have been numerous studies showing that many popular drugs that may have improved lab tests for cholesterol failed to reduce risk. These studies led the authors of the guidelines to make a distinction between proven and unproven medications.
Thus, the focus of the guidelines is on statins, the drug class with clear evidence that it can lower risk in many groups of patients. In fact, statins seem to lower risk regardless of your cholesterol levels. This fact has led many of us to think about statins as risk-reduction medications rather than just medications that modify cholesterol levels. Regardless, the evidence that statins lower risk is very clear.
So the guidelines now make clear that if you use drug therapy for higher risk, you should use statins. If you cannot tolerate one statin, you might want to try another statin, after consultation with your doctor. If you use another type of drug, then you should know whether that drug has been shown to reduce risk in contemporary studies. Many popular drugs, like Zetia (ezetimibe), have not yet been proven to save lives.
Bottom line: The new guidelines are a marked departure from the era of chasing targets and being agnostic to the drugs you used. The new message is don’t chase targets, know your risk, and — if you need drug therapy — use statins. These principles should guide your discussions with your doctor.