Last October two respected American medical organizations, the American College of Cardiology and the American Heart Association, released their much-anticipated new guidelines around treating cholesterol levels.
Anticipated because a big change was expected, and that change seemed likely to focus on one thing only – managing your lipid levels, or cholesterol, if you’re at risk for a heart attack or stroke. In other words — all of us.
The recommendations have stirred controversy for sure, but in our clinic they landed with a soft thud.
Basically the guidelines have ‘retired’ the practice of prescribing increasing doses of anti-lipid medication to get the patient to a specific blood lipid level.
Instead, medium or high intensity levels of treatment are now advised. What this means essentially is doubling or even tripling the usual dose of a statin prescription to reduce your lipid levels.
The accepted practice didn’t really reduce ‘heart events’ that much.
Besides, researchers found there could be a ‘halo’ effect of other benefits from using a statin beyond lowering your statin level, and thus your risk.
The guidelines divide us into four big risk groups:
“Big” means you have coronary heart disease and you’re under 75 years old.
Or you’re diabetic and are between 45 and 75.
Or your LDL cholesterol levels are high.
Or, finally, they aren’t high, but an online risk assessment puts your risk of heart disease over the next 10 years at 7.5 per cent or more.
All doctors are used to using algorithms to assess risk with our patients. We’ve used them with women to project their breast cancer risk and have comfortably used the Framingham Risk Calculator to discuss risk with both men and women patients. Indeed the Framingham data, collected since 1948, has provided the basis of our understanding of the evolution of heart disease for the past 60 years.
Dr. Bill Kannel, the revered ‘grey’ who had been there at the start outlined the legacy of that massive undertaking on the occasion of its 50th anniversary in 2006. Many of the seminal contributions we now take for granted. Afterall back in the 60s when I was in nursing school, smoking was considered a health benefit, touted as a means to relax jangled nerves.
But Framingham changed everything. Its data led to the elucidation of many other factors in heart disease including hypertension, diabetes, obesity and menopause as factors increasing CVD risk. Indeed it was Kannel who coined the very concept of multi-factorial risk with respect to heart disease.
The Framingham data led to the concepts of reversibility of the great inevitables – age, sex and family history. It is hard today to appreciate how hard a battle it was to convince the public that a terrible family history could be reversed by stopping smoking and achieving better control of your blood sugar and weight.
In 1979, Framingham researchers pronounced that a 5-fold increase in cardiovascular risk was generated by LDL plaque in coronary arteries. The finding ushered in a new era, as did the notion that diabetes was a predictable outcome of what came to be known as the metabolic syndrome. This conglomerate of obesity, hypertension, and elevated triglycerides/LDL cholesterol was another ground-breaking Framingham contribution to our understanding of what really raises our risk around heart disease.
And with that the world of medicine added Total/HDL cholesterol to a risk calculator that included age, sex, family history, hypertension and diabetes.
It is true that population studies are by definition slow to reveal their secrets.
It took years to add women and other non-white populations to flesh out its largely white, male New England base. As doctors we came to accept the soundness and rigor of the study and the Framingham Risk calculator became the foundation of how we practice, how we assess, how we advise our patients about their heart health.
Zoom forward to today.
Newer data, generated largely by pharma companies, has been able to demonstrate easily, repeatedly and in large-scale studies, how lowering cholesterol can prevent cardiovascular events.
But these studies pointed out something else: even if you have none of the other risk factors, lowering LDL lipid levels will significantly reduce your chances of a heart attack or other cardiovascular event in the next 10 years.
This leads to a big question – with a complex answer.
So why not just start every 50-year-old Canadian on a cholesterol-lowering statin pill?
As you can imagine, the responses are often strident.
They include exorbitant cost, serious side effects, narrow and single-minded meddling, profiteering on the part of pharmaceutical companies to the exclusion of individual efforts, obliterating the essential dialogue between doctor and patient.
And those are just a few.
But however these issues play out, today the risk calculators for both Framingham and the new ASCVD calculator are available online as apps, and tens of thousands of people use them. Ten year and lifetime risk spreadsheets are available on the American Heart Association Website.
When I applied the new guidelines to myself, at age 70, my risk of cardiovascular disease event is 8 per cent. I exceeded the new guideline for taking a statin drug by .5 per cent.
The two American medical bodies suggest that anyone over 50 who has a risk of 7.5 per cent or more should automatically start taking statins.
But frankly, I’m not about to start on lipid-lowering drugs. I will continue to apply the tried and true – diet, activity, and portion control – to counter the one unalterable reality of my advancing age.
I consider myself part of the great wave of seniors who now need to balance the torrent of interventions and alternatives to delay and blunt decline, decay, and eventual demise. That last result is not in dispute. What is still up in the air for me as a patient is the perceived benefits vs. the perceived risks.
What I can say is that one of my male medical partners who is 65 and has a 10-year risk of heart disease calculated at 28 per cent, has no intention of starting any medication or doing anything new to improve his well-being.
He too will press on — biking daily to work, working out at the gym on the things he hates but needs to do, monitoring his fat intake and being content to be occasionally hungry.
I’m not saying we are 100 per cent right and the American Medical Colleges are 100 per cent wrong.
I’m saying, despite having much more available evidence of what can lower our risk of heart disease than we had even 5 years ago, on balance I’m not convinced enough – yet – to treat statin drugs as miracle drug.