On Monday, the two major cardiology bodies released new guidelines for statin prescriptions to people at high risk for cardiovascular disease.
An expert panel assembled by the American College of Cardiology and the American Heart Association issued the joint ACC/AHA recommendations. For the details, see our sidebar, “New guidelines downplay cholesterol”.
The guidelines drew immediate criticism from respected cardiologists and observers familiar with the medical literature
The ACC/AHA guidelines target cardiovascular disease caused by atherosclerosis (hardening and narrowing of the arteries), which can lead to heart attack, stroke, and sudden cardiac death.
New guidelines downplay cholesterol, focus on multiple risk factors
The new guidelines recommend moderate- or high-intensity statin therapy for four groups:
- Patients diagnosed with cardiovascular disease.
- Patients with an LDL, or “bad” cholesterol level of 190 mg/dL or higher.
- Patients with Type 2 diabetes who are between 40 and 75 years of age.
- Patients with an estimated 10-year risk of cardiovascular disease of 7.5 percent or higher who are between 40 and 75 years of age (the report provides formulas for calculating 10-year risk).
Rather than focusing narrowly on blood cholesterol, the guidelines recommend using current risk assessment tools “to find the patients most likely to benefit from statin therapy”.
According to ACC/AHA panel chairperson Neil J. Stone, M.D., “This guideline represents a departure … because it doesn't focus on specific target levels of … LDL, or ‘bad' cholesterol ... Instead, it focuses on defining groups for whom LDL lowering is proven to be most beneficial.”
That stance makes sense, because there's no evidence that non-statin drugs that only reduce LDL cholesterol levels (statins also reduce arterial inflammation) reduce the risk of heart attack or stroke.
Fortunately, the new guidelines recognize this fact, and advise doctors to stop adding other cholesterol-lowering drugs to statins.
In fact, conventional wisdom on fat and cholesterol appears flawed, as a cardiologist argued recently in amajor medical journal … see “Heart-Diet Myths Get a Busting
They identify four major groups of patients for whom statin drugs offer the greatest chance of preventing stroke and heart attacks.
Critics within the cardiology community say the guidelines rest on weak evidence and unsupported assertions. And they note that the previous ACC/AHA guidelines clearly suffered severe scientific shortcomings … a fact acknowledged implicitly by issuance of the new guidelines.
Chronic inflammation and other risk factors driven by the excessive intake of sugars, starches, and omega-6 fatty acids typical of the average American's diet appear more harmful, by far. See “America's Sickening Omega Imbalance
Guidelines projected to cause steep rise in statin prescriptions
Opponents of the guidelines agree with the expert panel about one thing: the new advice will greatly expand the number of people prescribed statin drugs.
According to ACC/AHA panel chairperson Neil J. Stone, M.D., “… more people who would benefit from statins are going to be on them, while fewer people who wouldn't benefit from statins are going to be on them.”
Critics fear that by greatly expanding the number of people on statin drugs, the new ACC/AHA guidelines will weaken patients' and doctors' focus on safe, proven-effective lifestyle changes … which yield broad benefits beyond cardiovascular disease.
One sharp rebuttal, published in The New York Times, came from two highly credible observers:
- Cardiologist Rita F. Redberg, M.D., editor of JAMA Internal Medicine and professor at the University of California, San Francisco Medical Center.
- John D. Abramson, a lecturer at Harvard Medical School and the author of “Overdosed America: The Broken Promise of American Medicine,” an expert in litigation involving the pharmaceutical industry.
As they wrote, the new cholesterol guidelines “essentially declared, in one fell swoop, that millions of healthy Americans should immediately start taking pills — namely statins — for undefined health ‘benefits'. According to our calculations, it will increase the number of healthy people for whom statins are recommended by nearly 70 percent.” (NYT 2013)
“This announcement is not …based on new data showing the benefits of lower cholesterol. Instead, it is a consequence of simply expanding the definition of who should take the drugs — a decision that will benefit the pharmaceutical industry more than anyone else.” (NYT 2013)
And Drs. Abramson and Redberg made a key, often-overlooked point: “…18 percent or more of [people prescribed statins] would experience side effects, including muscle pain or weakness, decreased cognitive function, increased risk of diabetes (especially for women), cataracts or sexual dysfunction.” (NYT 2013)
Diet and lifestyle may fade from focus
While the ACC/AHA guideline authors stress the importance of lifestyle, they claim – despite ample contradictory evidence – that when “someone already has atherosclerosis, lifestyle changes alone are not likely to be enough … and statin therapy will be necessary.”
As Drs. Abramson and Redberg noted in The New York Times, “… statins provide false reassurances that may discourage patients from taking the steps that actually reduce cardiovascular disease … 80 percent of [which] is caused by smoking, lack of exercise, an unhealthy diet, and other lifestyle factors. Statins give the illusion of protection to many people, who would be much better served, for example, by simply walking an extra 10 minutes per day.” (NYT 2013)
To the (modest) extent that statins prevent heart attacks and strokes in diagnosed heart patients, they don't do it only or even primarily via cholesterol-lowering … another point acknowledged implicitly in the new guidelines' de-emphasis of cholesterol-lowering.
Instead, there's ample evidence that statins' cardiovascular benefits stem from their anti-inflammatory effects … see “Cholesterol Fiasco Undermines Accepted Theory
”, which provides links to cogent critiques from The New York Times
and The Boston Globe
Nature offers a myriad of safer alternatives, like the omega-3 fatty acids in fish or fish oil, and the seriously anti-inflammatory “antioxidants” (polyphenols) in many plant foods.
Of course diet improvements offer a much safer way to control inflammation and improve blood cholesterol and fat profiles.
- American College of Cardiology and American Heart Association (ACC/AHA). ACC/AHA Publish New Guideline for Management of Blood Cholesterol; Update focuses on lifestyle, statin therapy for patients who most benefit. November 12, 2013. Accessed at http://newsroom.heart.org/news/acc-aha-publish-new-guideline-for-management-of-blood-cholesterol
- Stone NJ, Robinson J, Lichtenstein AH, Merz CN, Blum CB, Eckel RH, Goldberg AC, Gordon D, Levy D, Lloyd-Jones DM, McBride P, Schwartz JS, Shero ST, Smith SC Jr, Watson K, Wilson PW. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2013 Nov 12. [Epub ahead of print]
- The New York Times (NYT) / Abramson JD, Redberg RF. Don't Give More Patients Statins. November 13, 2013. Accessed at http://www.nytimes.com/2013/11/14/opinion/dont-give-more-patients-statins.html