A more personalized approach to treating high cholesterol
New guidelines refine the recommendations for treating the leading causes of death and disability.
Cholesterol, the waxy, fatlike substance that contributes to heart attacks and strokes, is among the best-known contributors to cardiovascular disease — and with good reason. For decades, doctors have recommended blood cholesterol testing, often during annual checkups. Nearly one in three American adults has high levels of LDL, the most harmful type of cholesterol. Expert advice on managing this common problem now takes a more personalized approach, according to updated guidelines released by the American College of Cardiology and American Heart Association last November.
“The new guidelines really codify and support what many preventive cardiologists already do,” says Dr. Jorge Plutzky, director of preventive cardiology at Harvard-affiliated Brigham and Women’s Hospital. They tailor treatment based not just on LDL values but also a person’s overall risk, he explains.
The guidelines continue to recommend an LDL-lowering statin for everyone who’s already had a heart attack or, in most cases, a stroke. And among such people, those whose LDL remains higher than 70 milligrams per deciliter (mg/dL) despite taking a high-intensity statin may also need additional drugs.
Advice for at-risk adults
For people who are at risk for cardiovascular disease but don’t yet have it, the guidelines offer detailed advice about who may benefit from taking a statin. For example, people ages 40 to 75 who have diabetes and an LDL of 70 or higher should take a statin; so should anyone with extremely high LDL (190 mg/dL or greater).
For people not in those categories, the guidelines advise doctors to use a calculator to assess a person’s 10-year risk for heart disease. You can do this yourself at www.health.harvard.edu/heartrisk. You’ll need to know your total and HDL cholesterol values and your blood pressure. The calculator also takes into account your age, sex, race, and smoking status.
The presence of one or more of the following factors may sway your doctor’s advice about whether you should take a statin:
From low to high risk
Regardless of LDL level, everyone should focus on healthy lifestyle choices. Beyond that, your risk score will guide your doctor’s treatment advice. Following are the general guidelines:
- Low (a score of less than 5%). A statin is not recommended.
- Borderline (a score of 5% to 7.4%). If you have one or more factors that add to your risk (see “Risk-enhancing factors”), discuss possible statin treatment with your doctor.
- Intermediate (a score of 7.5% to 19.9%). If you have one or more risk-enhancing factors, a moderate-intensity statin would be advised, with a goal of lowering LDL by 30% to 49%.
- High (a score of 20% or higher). Take a statin, with a goal of lowering LDL by at least 50%.
The inclusion of risk-enhancing factors is an example of how these new guidelines take a more personalized approach. But Dr. Plutzky cautions that the hard evidence and the relevance of these factors varies. For instance, having a father who had a heart attack before age 50 doubles your relative risk. But the influence of other factors (such as having rheumatoid arthritis or being of South Asian ancestry) is less certain.
For people at intermediate risk in whom the decision to take a statin could go either way, guidelines now suggest using a specialized x-ray called a coronary artery calcium scan. A result that shows calcium in the heart’s arteries suggests the process underlying most heart attacks is under way, which may help convince a person to take a statin. However, the scan certainly isn’t mandatory. Statins have an excellent safety profile and most people tolerate them well, which often simplifies the decision for people who’d rather avoid the test, says Dr. Plutzky.