The Medicine Cabinet-Ask the Harvard Experts: New guidelines changing the use of statins

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Q: I'm confused about when a person should start drug therapy to lower cholesterol. It used to be based on a number. What's the latest?

For years, doctors prescribed drugs to lower cholesterol based largely on blood test results. For most people, an LDL ("bad cholesterol") level of 130 milligrams per deciliter (mg/dL) of blood was enough to trigger concern. For people with coronary heart disease, the optimal LDL level was less than 70 mg/dL).

But recent guidelines on statin use proposed a major change to that strategy. The American Heart Association and the American College of Cardiology issued the guidelines in 2013.

The new guidelines take away this "target-driven" approach. They don't focus on the LDL numbers. Instead, they recommend using risk to decide when people should take a statin drug to lower LDL cholesterol. Statins are best because they do more than just lower a number. They reduce risk of developing heart disease and having a stroke.

You should be taking a statin if you have:

--Artery disease, including angina, a previous heart attack or stroke, or other related conditions

--A very high level of harmful LDL cholesterol (generally at or above 190 mg/dL)

--Diabetes, if you are also 40 or older

For everyone else, you and your doctor will focus on the risk score. High risk means a greater than 7.5 percent chance of having a heart attack or stroke within 10 years.

Whether to take a statin will be a decision that you make with your doctor. It depends on how many factors you have that increase your risk. Risk factors include:

1. A parent, brother or sister who had coronary artery disease or stroke at an early age (a man before age 55 or a woman before age 65)

2. Tobacco use

3. High blood pressure

4. A low HDL ("good cholesterol") level (under 40 milligrams per deciliter)

If you do start a statin, the goals have changed. You don't need to lower your LDL level to a specific number. Instead, you start at a low dose and work up to a certain "intensity" of statin treatment:

Moderate-intensity treatment lowers LDL by 30 percent to 50 percent.

High-intensity treatment lowers LDL by 50 percent or more.

(Howard LeWine, M.D., is a practicing internist at Brigham and Women's Hospital in Boston and Chief Medical Editor of Internet Publishing at Harvard Health Publications, Harvard Medical School.

(For additional consumer health information, please visit http://www.health.harvard.edu.)

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