Cholesterol Turmoil Leaves Patients
& Their Doctors With Questions
The cholesterol cops are at it again – only this time the storm they’ve stirred up makes them look more like the Keystone Cops. The latest cholesterol guidelines and the new risk calculator being recommended for prescribing cholesterol-lowering statin drugs are starting to take on the aura of the Obamacare website fiasco.
The latest guidelines for lowering cholesterol have finally abandoned the notion of driving “bad” (LDL) cholesterol below 100 or even 70 for many patients, as there’s no evidence that attaining these ultra-low targets adds any survival benefit (and there IS some evidence, gone unmentioned, that it may cause harm).
That’s the good news. The bad news is they want to replace these aggressive cholesterol targets with a “risk calculator” that’s guaranteed to make cholesterol drug manufacturers jump with glee. If doctors use this calculator, the use of cholesterol-lowering drugs – exclusively statin drugs as the guidelines discourage other cholesterol-lowering drugs – will essentially double, mostly for those with no history of cardiac problems.
This is called “primary prevention” and using statins for this purpose has long been a source of controversy. The drug manufacturers themselves acknowledge that only 1 in 100 patients taking statins for primary prevention – or to prevent a first cardiac event – actually benefit. The other 99 get no benefit, but still incur their costs and side effects that include increased risk of type 2 diabetes, memory problems, and muscle pain that inhibits healthy lifestyle choices.
Ask yourself where else in your life you’d do something where the odds were against you 99 to 1.
And now they want to double down with those worse-than-Vegas odds by relying on an unproven risk calculator that’s coming under increasing criticism from some highly unlikely medical sources.
Relying on Old Data
According to a report in today’s Boston Globeabout an article to appear in tomorrow’s The Lancet medical journal – how’s that for timely? – two Harvard researchers found “The calculator was not working among the populations it was tested on by the guideline makers”.
One reason for this discrepancy seems to be that the studies the calculator relies on were done in the 1990’s when more people smoked and had heart attacks and strokes earlier in life than they do today. So while actual risk for these cardiac events has declined since then, our doctors are being told to employ more aggressive tactics – more statin drugs – based on data when these risks were higher.
This delayed reaction will now subject millions more Americans to the risks of over-treatment with statin drugs that aren’t actually needed.
What’s surprising with this report is that one of the Harvard researchers – Dr. Paul Ridker – headed the Jupiter Study that encouraged much broader use of statins based on elevated CRP levels of inflammation rather than cholesterol levels alone. The fact that he held a patent for the CRP test caused intense criticism of this apparent potential conflict of interest.
Another Unlikely Voice of Dissent
And another report from MedPage Today adds Dr. Steven Nissen of The Cleveland Clinic to the list of naysayers. Nissen has long advocated aggressive statin therapy to reverse atherosclerosis, so his criticism is also from an unexpected source.
According to a report in today’s New York Times, Dr. Nissen is suggesting a “time out” for the new cholesterol guidelines. He’s quotes as saying:
“It’s stunning. We need a pause to further evaluate this approach before it is implemented on a widespread basis.”
The article goes on to say the controversy has thrown the ongoing annual meeting of the American Heart Association into “turmoil” as the nation’s cardiologists struggle to make sense of the current cholesterol chaos.
What’s a MedSmart Patient To Do?
For starters, if you’re not already on a statin, don’t be quick to start on one based on this latest clinical curfuffle. If you’re at high risk for cardiac disease because you’re a diabetic or obese, then you should probably already be on a statin. That’s not the end of the risk spectrum that’s in dispute.
It’s the other, low-risk end of the spectrum where the controversy rages anew. If you haven’t had a prior cardiac event and aren’t otherwise at high or even moderate risk for one, it may be wise to pass on a statin drug and rely instead on proven lifestyle behaviors that can also lower your cardiac risk without the downsides of statin drugs.
So how do you know what your risk actually is?
Well, I wouldn’t rely on the tool that’s currently in such dispute, that’s for sure. The Mayo Clinic has a more reliable set of tools at their Statin Decision Aid website that allows you to use one of three different risk calculators based on what lab test results you have available to you.
If you have your CRP score for inflammation, for example, it will suggest you use the Reynolds calculator, which I found to be the most conservative of the three calculators available there when entering my own personal data and lab test results.
These new disputed cholesterol guidelines have lowered the bar by suggesting that anyone with a ten-year cardiac risk of 71/2% or higher should be prescribed a statin, up from prior suggestions starting at a 10% risk. This is what would double the number of such low-risk people now taking statins – something that has thoughtful clinicians properly concerned.
Until the dust settles, it may be best to avoid taking a statin anew if your risk is under 10% and to use caution even above that level. Using the 71/2% threshold, for example, all men aged 70-75 would be prescribed a statin regardless of their health status or cardiac history. And half of men aged 50-60 would also be on them.
Any time 100% of any patient cohort is recommended to be prescribed a given medication, it may be time to question what’s going on.
And try to keep your cholesterol in perspective – something that’s often lost in modern medicine that’s dominated by the “silo” thinking of whatever medical specialty in which you’re being treated. Yes, cholesterol – especially very small LDL cholesterol particles that more easily form plaque on artery walls – can prove dangerous if it’s at excessive levels in your bloodstream. But what’s excessive varies with age, gender, race, and other variables.
Cholesterol is natural and serves essential roles in preserving a healthy mind and body. These include maintaining porous cell membranes – one reason statin drugs increase type 2 diabetes risk is they lower cholesterol so much that the cells in your body are less able to absorb insulin and nutrients that keep blood sugar at healthy levels. The same applies to brain cells and explain the effects these drugs have on mood and memory.
And, finally, I’d also stay tuned for more on this subject – because it doesn’t appear likely to be resolved anytime soon.