The American Heart Association and the American College of Cardiology have just released new guidelines that could essentially double the number of Americans taking the cholesterol-lowering drugs known as statins. While the new guidelines aim to employ statins as a preventative measure to stave off heart attacks and stroke, I am concerned they may target too broad a population and de-emphasize healthy lifestyle changes that have been shown to reduce cholesterol and other risk factors in the hope of reducing heart attack and stroke risk. I fear that under the new guidelines, many people who would otherwise be able to manage their cardiovascular risk through nonpharmaceutical means will be pressured to take a medication which may not benefit them and could have harmful side effects.
This announcement represents a huge shift in how doctors would approach prescribing statins to their patients. The new guidelines go far beyond cholesterol numbers to place a much larger and more specific emphasis on other risk factors for heart attack. Under the new guidelines, moderate or high-intensity statin therapy would be recommended to the following groups:
- Any person with a history of cardiovascular disease, stroke, transient ischemic attacks, peripheral artery disease or coronary or arterial revascularization.
- People between the ages of 40 and 75 who have no cardiovascular disease but do have a 10 year risk of heart attack or stroke that is 7.5% or higher. Previous recommendations were that those who had a 10 year risk over 20% should take a statin.
- People over the age of 21 who have LDL (bad cholesterol) levels 190 or greater.
- People with type 1 or type 2 diabetes who are between the ages of 40 and 75.
This means that some people without high cholesterol would theoretically be prescribed statins, while others who have been taking statins due only to slightly elevated cholesterol numbers may not require a statin. For example, the frustrating implication of the new guidelines is that statins may now be recommended to a 60-year-old smoker with high blood pressure or a 50-year-old diabetic with no other risk factors. Treating the underlying problem appears to be a more precise approach than tossing another medication onto the problem, especially when the medication is primarily addressing cholesterol. Before you make any changes to your medication regimen, always talk to your doctor.
While statins are often effective at lowering cholesterol, I am concerned that their benefits may not be as great as many proclaim, and that their downsides have often been de-emphasized. Statin use is already widespread in the U.S., and some experts believe they are already being overprescribed. A quarter of Americans over the age of 45 take a statin, according to the Centers for Disease Control and Prevention (CDC). Certainly for those who need them, they can quickly lower bad cholesterol and are often life-saving drugs. However, studies on whether they are effective at preventing death for people without heart disease – particularly women – have often yielded conflicting and inconclusive results. Research on what really causes heart attacks is rapidly evolving, and the cholesterol-lowering solution is clearly not the only culprit we need to target.
Statins are also not without risk. Their potential side effects include muscle pain, muscle damage, an increased risk of diabetes (particularly in women), digestive problems such as nausea, diarrhea and constipation, memory loss or confusion (though this is being hotly debated) and, rarely, serious liver damage.
I believe that many people can improve their cholesterol and their overall heart attack risk without resorting to statins. A Mediterranean diet, smoking cessation and exercise have been shown to lower the risk of (and sometimes even resolve) heart disease and diabetes. There are some people who are very high risk, with personal medical or family histories that improvements in lifestyle cannot change. For these people, statins are an effective and often necessary option to protect their well-being and extend their lives. But for many other people at average risk or who do not suffer from high cholesterol, I am skeptical that statins should form the very first line of defense.