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Last Updated: Wednesday, 19-Feb-2014 17:00:00 EST
From Providence Journal: Karen E. Aspry and Charles B. Eaton: Fight Heart Disease with Shared Decisions about Statins
BY KAREN E. ASPRY AND CHARLES B. EATON
The new Cholesterol Treatment Guidelines released by the American College of Cardiology and American Heart Association last November generated wide discussion. What was not debated is the high prevalence of atherosclerosis-related death and disability in the U.S.
Almost 40 percent of American women and 50 percent of men will have a fatal or non-fatal heart attack, stroke or other cardiovascular event in their lifetimes, usually from a combination of abnormal blood cholesterol and other risk factors. A large proportion of these events will occur before the age of full life expectancy and without warning.
Having naturally normal blood cholesterol, blood pressure, blood sugar and body weight, and a healthy lifestyle that includes not smoking, exercising daily, and a plant-rich diet low in saturated fat dramatically reduces this risk. Unfortunately, less than 10 percent of adult Americans fall into this “ideal risk” category. The American Heart Association calls on the other 90 percent of us to examine our risks, most of which can be changed, and take steps to reduce them.
For those with known atherosclerosis (plaque buildup in coronary, peripheral, carotid or other arteries) or diabetes, one of these steps is to take a statin drug. In these high-risk groups, numerous clinical trials have shown that taking a moderate dose of a statin daily reduces the risk of a heart attack, stroke or other cardiovascular event by about 25 percent compared with a placebo. Higher doses lower risk an additional 15 percent. Death from all causes is reduced as well.
Not all the reduction in risk is from lowered cholesterol, suggesting that statins have “non-lipid” benefits. In a major departure from previous cholesterol guidelines, the new version recommends that all with atherosclerosis or diabetes take statins in moderate or high doses, and that providers focus on adherence, not specific cholesterol numbers or “targets.”
The most controversial issue in prevention is whether those without known cardiovascular disease, but at high future risk, should be treated similarly. Numerous studies of at-risk men and women show statins reduce first cardiovascular events by the same relative amount as occurs in those who already have the disease. It confirms what we already know from autopsy studies — that atherosclerotic plaques begin decades before heart attacks and strokes occur, and lowering blood levels of the cholesterol-rich particles that cause their build-up reduces risk anywhere along the continuum.
The new cholesterol treatment guideline simplifies risk assessment and treatment for providers and at-risk patients: Diet and lifestyle change remain the cornerstone.
If LDL (bad) cholesterol remains 190mg/dl or higher after diet and exercise, a genetic cholesterol disorder is likely, and a statin is recommended. (Of note, one of these disorders, familial hypercholesterolemia, is more prevalent in Rhode Island because of its large French-Canadian population.)
In all others, risk should be estimated via a new tool that calculates the likelihood of either a heart attack or stroke in 10 years and over one’s lifetime in both whites and African-Americans. If 10-year risk is 7.5 percent or higher, a frank discussion about one’s risk and the pros and cons of taking a statin should occur. Patients and providers should share in the decision making.
If a statin is decided on, at least a moderate dose is recommended. Once on a statin, the focus should be on adherence.
The decision to consider statins in those with 10-year risk as low as 7.5 percent was based on clinical trials showing this group obtains a benefit. Confidence in the safety of statins was based on studies showing users have a 1-in-1 million risk of liver failure (the same as non-users), a 2-in-100,000 risk of life-threatening muscle disease and, in those with pre-diabetes, a 15 percent risk of developing diabetes but a reduction in heart-attack risk anyway.
In sum, the goal is to raise awareness of the No. 1 killer of Americans and the fact that most of us are somewhere on the continuum of risk. New prevention guidelines offer a strictly evidence-based approach to cardiovascular risk estimation and risk reduction though diet and lifestyle change, and statin therapy in doses matched to one’s risk.
But as the principal author said, “The real beauty of the new guideline is that it puts the patient at the center,” empowered by information and engaged in shared decision making about how best to reduce his or her own risk.
Karen E. Aspry, M.D., is director of the Lipid and Prevention Program of the Lifespan Cardiovascular Institute and an assistant professor of medicine at Brown University. Charles B. Eaton, M.D., is director of the Heart Disease Prevention Center at Memorial Hospital of Rhode Island and a professor of family medicine and epidemiology at Brown.