Radical Change in Cholesterol Treatment… The 2014 Guidelines
For almost 15 years, physicians have been following the same cholesterol treatment guideline despite new research questioning whether or not this is the best approach. In January, a new guideline was finally released which will alter how we think about using medications to lower cholesterol levels. The new guideline uses the concept of “evidenced based medicine”; which means that all of the recommendations have their origin in science that has demonstrated reductions in stroke and heart attack.The new guideline differs in several fundamental ways.First, the old guideline was all about the number - the higher the cholesterol, the more likely it would need to be treated.The new guideline is all about the future risk of stroke and heart attack, which after all, is why we treat elevated cholesterol levels. It takes into account the cholesterol level, but also looks at other risk factors such as age, sex, race, diabetes, high blood pressure, and smoking history. All of these factors allow the prediction of future risk of stroke and heart attack, and if that risk exceeds 7.5% over 10 years, then medication is recommended.Secondly, the ‘target cholesterol number’ indicator that patients and physicians have used, that taught that the bad cholesterol (LDL) number had to be less than 100, is no longer the guide.
In the new guideline, it is recommended that people at moderate risk for future stroke and heart attack receive moderate doses of statin medications. People who have already had a stroke or heart attack, or those with diabetes are at higher risk for future stroke and heart attack and therefore; it is recommended that these individuals receive high doses of statin medications. This is based on evidence that suggests that the degree to which LDL cholesterol levels are reduced is more important than how low the LDL cholesterol actually is.
Thirdly, the automatic prescribing of medications to either reduce triglycerides or raise good cholesterol levels (HDL Cholesterol) is no longer recommended.
Unless triglyceride levels are markedly elevated (>500), the new guideline no longer recommends medications which were chiefly aimed at either reducing triglycerides or raising good cholesterol levels (HDL cholesterol). Although these medications “improve the cholesterol profile”, they have not been conclusively shown to reduce the incidence of stroke and heart attack (niacin and the class of medications known as fibrates fall into this category).
Lastly, and perhaps most importantly, we have known for years that some individuals with low cholesterol levels suffer stroke and heart attack while others with very high levels do not. For the first time, the new guideline endorses vascular screening tests. These are simple and inexpensive tests which can see which individuals are beginning to block their arteries and which are not. The two most commonly used tests are the coronary calcium score using a CAT scan, and the CIMT test which uses ultrasound to examine the carotid arteries. Using these tests to determine who might best benefit from cholesterol lowering medication can be enormously beneficial. It can often serve as the decision point between needing medication and not needing medication in borderline situations.
So how do we best use this new guideline? At your next visit with your primary care physician, engage in a discussion as to whether the new guideline should alter any current approach to screening or treating an abnormal cholesterol level. Of course, this new science does not trump what we have known for decades. Namely, there is no better start to promoting future health than a combination of a heart healthy diet and regular exercise.
For additional information about Cholesterol.
Ken Cohen, MD, FACP, CMO
Evergreen Internal Medicine