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For decades, people who take a serious look at the evidence for cholesterol as the sole cause of heart disease have been skeptical, and of the use of statins to lower them. Apparently they have been heard.

For over 25 years, tens of millions of Americans have been told they need to take a statin medication to get their cholesterol levels down. 

Under the new approach recently announced by the American Heart Association and the American College of Cardiology, they will just be told they need to take a statin medication, and they will not be expected necessarily to meet cholesterol goals.

Three New Broad Risk Categories

The new approach creates three broad risk categories requiring statin treatment.

Statins will be routinely prescribed to people who already have a condition that increases their risk of cardiovascular disease, such as diabetes, or a prior heart attack.
Statins will also be routinely prescribed to people who have dangerously high levels of "bad," LDL cholesterol, to everyone who has an LDL of 190 or higher.

Also asked to take statins will be everyone else who has a risk of at least 7.5% of having a heart attack or stroke in the next 10 years, based on a calculation with an online spreadsheet tool that takes into consideration age, blood pressure, total cholesterol level, and ethnicity.

But people in these categories will no longer be told to get their cholesterol down to 70 or lower by rigorous dieting or increasing dosages or by switching medications, typically to Crestor (rosuvastatin). The new risk guidelines calculate risk of stroke as well as risk of heart attack, unlike old calculations of cardiovascular risk. 

Some People Will Come Off Statins, Some People Will Go on Them

Before the new guidelines, "high cholesterol" was considered to be a sufficient reason by itself to be placed on statin drugs. 

Under the new guidelines, high LDL cholesterol still will be, but when total cholesterol is the only risk factor, statin treatment will no longer be considered unnecessary.

On the other hand, the new guidelines take into account the fact that African-Americans are at substantially greater risk than the rest of the American population for stroke, and many African-Americans who have high blood pressure but lower levels of cholesterol who are not on statins now will be asked to take them.

Non-Statin Cholesterol-Lowering Medications Likely to Be Less Often Prescribed

Since the new guidelines do not require reaching a specific lower cholesterol number, non-statin cholesterol-lowering medications like Zetia (generic name etizimibe, also marketed as Ezetrol) are less likely to be prescribed.

Zetia lowers cholesterol levels by blocking the absorption of cholesterol from food. Because the cholesterol stays in the intestines, the drug commonly causes constipation, sometimes offsetting the constipation caused by the statin drug. But adding cholesterol-lowering drugs to other cholesterol-lowering drugs has never been shown actually to lower the risk of heart attacks and strokes.

Doctors Resist the Idea of Prescribing Fewer Statins

Perhaps predictably, many doctors are already raising objections to changing standards they have used for years.

The new guidelines take age into account.

Someone under the age of 20 would almost never be prescribed a statin, for instance. But some doctors believe that keeping LDL levels to a minimum would stop cardiovascular damage from ever occurring. There is, however, no evidence of lowering normal LDL levels by drugs actually prevents heart attack of stroke.

Continue reading after recommendations

  • 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013. doi:10.1016/j.jacc.2013.11.003.
  • Kolata G. Experts reshape treatment guide for cholesterol. New York Times. 13 November 2013.
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