You may be wondering what to do, if anything, about your cholesterol levels.
Many people, including health professionals, are still puzzling over a groundbreaking revision of cholesterol guidelines that was released almost two years ago. The guideline, from the American College of Cardiology and the American Heart Association, represented years of analyzing the medical literature to produce recommendations about who should be treated with cholesterol-lowering drugs.
The big change was moving the focus for the decision about treatment — from your cholesterol numbers to your overall risk of dying from coronary heart disease or having a heart attack or stroke. The idea is that the higher your risk, the more you have to gain from these drugs. Conversely, the lower your risk, the less likely you are to benefit.
A great ruckus followed the publication of these changes. After decades of focus on patients knowing their numbers and reaching cholesterol targets, the new approach took people by surprise. Even now, people, including doctors, are having trouble making the change in their thinking.
In this week's JAMA, the journal of the American Medical Association, two articles tackle issues with the new guideline. One article compared the new guideline with the old guideline for their ability to identify people who would benefit from statin therapy. Researchers studied people enrolled in the Framingham Heart Study, the granddaddy of our epidemiology studies of cardiovascular risk. The researchers found that the new guideline, with its emphasis on risks instead of targets, was more accurate and efficient in identifying people with an increased risk of cardiovascular disease.
In essence, they find that the new guideline identifies more people for treatment – but that they are people who are likely to benefit from treatment. This article strengthens the case for the wisdom of the change in approach to the decision to use statins.
The new guideline was also controversial because of its definition of what constitutes high risk among those individuals without known cardiovascular disease. It recommends statin treatment for people with cardiovascular diseases, such as having had a heart attack or stroke, or for those with diabetes even if they have not had prior heart disease. For others, they recommend treatment if a person's risk is greater than 7.5 percent in the next 10 years.
In the other JAMA study, scientists investigated the economic implications of various thresholds for treatment. Using an economic simulation model, they found that the 7.5 percent risk threshold was economically attractive compared with many other investments in health care. And, in fact, they found that even a risk as low as 4 percent was economically attractive for society.
For people contemplating statin therapy, the cost is quite low anyway. Most statins are generic now, and several can be bought for only a few dollars a month.
From my perspective, the researchers' findings give further support to the efforts to base the decision on the patient's preferences. It is not unreasonable from an economic perspective to support treatment decisions for even those who have a low risk of cardiovascular disease (lower than 0.5 percent a year), the researchers are saying.
The issue is the need to weigh known and unknown side effects, which are particularly important for those with low risk of heart disease and stroke and less likelihood of benefit.
The drugs are generally safe. But known side effects may involve muscle problems and diabetes, among other. The unknown side effects are, well, unknown, but there is always a possibility that lifelong therapy will involve some issue that we have yet to discover.
So what about your decision?
In the end, I don't believe the guidelines should dictate what people should do, but only suggest how they might think about their choices.
One of the new studies endorses the idea that treating based on cardiovascular disease risk is better than treating based on some target level. The other one suggests that treatment based on risk should be available to even low-risk people if they want treatment. We should also be clear that for them, the benefit is small and could easily be offset by any aversion to taking medications or concern about side effects.
For anyone, the decision should be about whether the potential benefit is big enough to you, based on your preferences, to make it worth taking a pill every day.
Harlan Krumholz is a cardiologist and the Harold H. Hines Jr. Professor of Medicine at Yale University School of Medicine. He directs the Yale-New Haven Hospital Center for Outcomes Research and Evaluation and is a director of the Robert Wood Johnson Clinical Scholars Program at Yale.
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