Essential Info About Statin Guidelines

When the American College of Cardiology (ACC) and American Heart Association (AHA) jointly released revised guidelines for prescribing cholesterol-lowering statin drugs late last year, the organizations sparked confusion within the medical community.

The new guidelines, which controversially recommend high-dose statins for a much wider swath of the American population, no longer set target goals for healthy cholesterol levels. Instead, they rely almost exclusively on evaluating risk factors that many physicians complain may under-represent at-risk young people and over-represent healthy older people.

So if the new regulations leave doctors scratching their heads, how can you make sense of them? Here’s what you need to know.

Do You Need a Statin?

You should take a high dose of statins if:

• You've had a heart attack or have been diagnosed with heart disease. 
• Your level of LDL, the damaging kind of cholesterol, is 190 mg/dL or higher. 
• You’re diabetic.

If you fit into any of these categories, you’ll likely notice two straightforward but significant changes at your next doctor visit:

• First, he or she may now aim to reduce your LDL level by 50% instead of shooting for a specific number. 
• Second, he or she will probably put you on a high statin dose and reduce it if you’re not tolerating the side effects well. This approach departs from the traditional method that called for doctors to start patients on a low dose and raise it if LDL levels didn’t drop.

To Dose or Not to Dose?

Virtua cardiologist Maria Duca, MD, questions this departure because statins can cause liver inflammation, which can be managed fairly easily by altering the prescription, and severe muscle pain, which can’t.

“Many people stop taking statins because of the severity of the muscle aches. The higher the dose the more likely the side effects,” she says. Luckily, the FDA has approved various types of statins and a few other cholesterol-reducing drugs that don’t normally cause the same intense side effects.

Who’s Really at Risk – The Young, Old or Those In Between?

The controversy over the guidelines doesn’t end with dose. The ACC and AHA have added an entirely new category of patient who should take high-dose statins – those who have a 7.5% or higher chance of having a heart attack or stroke in the next 10 years, as indicated by the organizations' updated health-risk calculator. Many physicians find this logic faulty because they say the groups are recommending preventative medication for too many people, and at a prematurely high dose.

Plus, critics argue that although the new calculator finally factors in race and ethnicity, it leaves out a crucial component of risk: family history.

“Say your dad had a heart attack at 35,” says Dr. Duca, “there’s no box in the new health-risk calculator to account for that family history, and that’s important.”

The Age Factor

Because the guidelines don’t apply to individuals younger than age 40, 20- and 30-something patients with a family history can get overlooked. And the emphasis the calculator places on age might make middle-aged and baby boomer patients with no family history score artificially high.

What’s more, observes Dr. Duca, the recommendations don’t apply to anyone over age 75, so she worries about prescribing statins to her oldest patients. This poses a particular problem in evaluating women because, as she says, “women’s heart disease starts in our 60s,” whereas men typically develop heart disease earlier.

What to Do Now

So now what? Despite the best efforts of the ACC and the AHA to update the guidelines for the first time in a decade, clear answers still elude medical practitioners and their patients.

“The new guidelines may be confusing, but maintaining a healthy heart is a clear goal for everyone.” Dr. Duca’s best advice: “Schedule a visit with your doctor to discuss how the new guidelines apply to you and your health.” 

Updated December 29, 2017