New Cardiovascular Disease Guidelines Could Double Use of Statins

Published November 20, 2013 | By Lisa Nelson, RD

On Tuesday, November 12^th, the American Heart Association and the American College of Cardiology jointly published prevention guidelines. The guidelines focus on the treatment of blood cholesterol to reduce heart disease, lifestyle management to reduce heart disease, overweight/obesity management, and cardiovascular risk assessment. These new guidelines call for a focus on risk factors and not just cholesterol levels.

Up until now, the focus has been on “bad” cholesterol — LDL cholesterol — levels and the need to keep LDL cholesterol below 100 mg/dL. Instead of using LDL cholesterol levels to determine if cholesterol lowering statin drugs should be prescribed, the new guidelines look at risk factors.

Here are four questions used to assess risk:

Do you have heart disease?
Do you have diabetes (Type 1 or Type 2)?
Do you have a bad cholesterol level greater than 190 mg/dl?
Is your 10-year risk of a arteriosclerotic/atherosclerotic cardiovascular disease (ASCVD) event greater than 7.5%?

Base on the new guidelines, if your answer was “yes”, to any of the above four questions, you should be prescribed a statin medication. If you answered “no” to all, then lifestyle and behavior modification should be adequate to manage high cholesterol.

How do you know if your 10-year risk of a ASCVD event is greater than 7.5%? The committee states they have created very robust equations – Pooled Cohort Equations – that take into account age, sex, race, total HDL cholesterol, blood pressure, diabetes, smoking habits, and blood pressure treatment to determine risk. You can learn more about this calculator to calculate your risk here.

The new guidelines identify what “intensity” of statin therapy a patient should receive. According to the new guidelines, less is not always best. A higher dose may lead to greater results and reduce the need for other medications. It’s estimated that these new guidelines will double the number of individuals prescribed statin medications. It’s important that the potential side effects connected to statin medications not be downplayed – muscle pain and soreness, increase in liver disease and risk for type 2 diabetes. The new guidelines do include safety recommendations for statin use and the importance of selecting the appropriate statin and dose in men and nonpregnant/nonnursing women based on patient characteristics, risk level, and potential side effects. However, the guidelines do not recommend routine monitoring of creatine kinase levels unless patient is believed to be at increased risk or has shown adverse reactions in the past, same approach with monitoring hepatic function. The guidelines do encourage those receiving statin medications to be evaluated for new-onset diabetes.

These new recommendations were determined after careful review of an extensive body of quality evidence from randomized control trials. Rather than using LDL or HDL cholesterol as targets to treat risk, the new guidelines focus on statin therapy as the goal treatment. Researchers identified four groups of individuals who showed a reduction in ASCVD events when treated with statins. These four groups include:

Individuals with clinical ASCVD
Individuals with primary elevations in LDL >190 mg/dL.
Individuals 40 to 75 years-old with diabetes and LDL 70-189 mg/dL without clinical ASCVD.
Individuals without clinical ASCVD or diabetes between the ages of 40 to 75 years-old with LDL 70-189 mg/dL and an estimated 10-year ASCVD risk of 7.5% or higher.

Hence where the four assessment questions above came from.

The new guidelines released included emphasis on a heart healthy diet by decreasing saturated and trans fats and limiting sodium to 2400 milligrams per day. Specific diet plans referenced include the DASH Diet, USDA Food Pattern, and AHA Diet. The goal is to reduce saturated fat to 5-6% of calories.

Guidelines recommend physical activity of 3 to 4 sessions per week, lasting an average of 40 minutes per session of moderate to vigorous intensity.

The American Heart Association and American College of Cardiology also called for physicians to take an individualized approach to weight loss with their patients and encouraged referrals to dietitians for at least six months. It’s recommended for those with a BMI greater than 40 to be referred for a bariatric surgery consultation and evaluation.

I am generally against the use of medication unless lifestyle and diet changes do not work, so I’m not exited to review these new guidelines. For another view point on these recommendations, you may want to read what Dr. Stephan Sinatra wrote: New Statin Guidelines Could Dangerously Double Their Use.

All the best,
Lisa Nelson