New guidelines changing the use of statins

The Medicine Cabinet

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.

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