Tim Russert’s sudden death from a heart attack in 2008 took America by surprise. It seemed clear to everybody that a good man died too young. But the condition that killed him—coronary artery disease–is actually the most common cause of death in the U.S. and around the world.
In coronary artery disease (CAD) is a waxy substance called plaque builds up inside arteries that supply blood to the heart. Fortunately, over the past few decades many less people are dying of this disease. As this New England Journal of Medicine article demonstrates, the reduction of cholesterol is the single greatest factor explaining the decrease in deaths from coronary artery disease.
So it was significant when on November 12, 2013, the American College of Cardiology released new guidelines for treating cholesterol. Here are some of the key points from the guidelines.
First, the guidelines emphasized that only the cholesterol medicines called statins have been shown to reduce the risk of developing and dying from coronary artery disease. Although other medicines such as Zetia, Niacin, and Tricor do lower cholesterol, they don’t have robust evidence for lowering your risk of getting and dying from a heart attack.
Secondly, the guidelines no longer recommend aiming for a target cholesterol level. Formerly, physicians and patients would try to lower cholesterol below a certain number. But in the studies that show statins reduce the risk of heart disease, patients were placed on either a statin or placebo and then followed to look for a difference in the incidence of heart attacks. Thus, faithfully translating these studies into practice means simply putting people with or at risk of coronary artery disease on a statin.
And who is at risk for coronary artery disease? Who should doctors put on a statin? The guidelines point to the following 4 groups of individuals who benefit from these drugs:
1) People with a history of coronary artery disease (CAD) or cerebrovascular disease. The latter refers to folks who have had a stroke or mini-stroke
2) People with LDL cholesterol levels above 190. LDL is considered the bad cholesterol since it deposits plaque in arteries. People with very high levels of LDL have been found to experience a higher incidence of heart disease and at a younger age.
3) People with diabetes, age 40-75. Statins are recommended for diabetics since they have a markedly higher risk of developing CAD.
4) People aged 40-75 who have a 7.5% risk or higher of developing CAD in the next 10 years. This is the most controversial of the new guidelines. Since many people have over a 7.5% risk of developing CAD in the next ten years, if this recommendation is put into practice, a good deal more folks will be placed on statins.
Overall, I see these guidelines as a welcome advance. They better reflect what the studies on cholesterol and CAD actually tell us. They also simplify treating cholesterol. Rather than aiming for a certain cholesterol number, patients and doctors can now focus on deciding whether starting a statin will be beneficial in their individual situations.