Recently, the American Heart Association and the American College of Cardiology issued new guidelines on the management of cholesterol. The idea that individuals should be treated on the basis of their LDL-cholesterol level has been significantly relaxed. What this means, is that some individuals with ‘raised’ cholesterol but who are deemed to be at low risk of cardiovascular disease may now reconsider the appropriateness of statins.

However, while this rule has been relaxed, others have been tightened. Specifically, the new guidelines recommend expanding treatment to those at lower risk of cardiovascular disease than was previously advised. In the past, guidelines urgedtreatment for individuals for whom risk of developing cardiovascular disease was calculated to be between 10-20 per cent over the next 10 years. Now that threshold has been set at 7.5 per cent. Also, every middle-aged person with type 2 diabetes will be advised to take a statin – irrespective of risk. Overall, the number of people taking medication for cholesterol is set to rise by about 70 per cent.

Each time cholesterol guidelines are issued they expand the numbers of people eligible for treatment. In the past, I feel there’s been a natural tendency for doctors to accept these recommendations and act on them dutifully and, perhaps, without thinking. However, this time, I sense the mood is somewhat different. There has been vocal public opposition to the guidelines from some quarters, some of which has even made its way into the mainstream press.

An example is this opinion piece published in The New York Times written by Professor Rita Redberg (cardiologist and editor of the journal JAMA Internal Medicine) and Dr John Abramson (lecturer at Harvard Medical School). In reference to the expansion of those eligible for treatment, the authors say this: “This may sound like good news for patients, and it would be — if statins actually offered meaningful protection from our No. 1 killer, heart disease; if they helped people live longer or better; and if they had minimal adverse side effects. However, none of these are the case.”

They reference a recent piece co-authored by Dr Abramson and published in the British Medical Journal [1] that shows that 140 low-risk individuals would need to be treated to prevent one heart attack or stroke, and there would be no overall reduction in death or serious illness. At the same time, though, 18 percent or more of this group would experience side effects such as muscle pain or weakness, decreased brain function, increased risk of diabetes, cataracts or sexual dysfunction.

The New York Times piece also draws our attention to the fact that ‘popping a pill’ may give some a false sense of security, who may benefit far more from lifestyle interventions around, say, diet, exercise and smoking cessation.

The authors also highlight the potential conflicts of interest that may drive recommendations that are unsupported by the evidence, writing:

The process by which these latest guidelines were developed gives rise to further skepticism. The group that wrote the recommendations was not sufficiently free of conflicts of interest; several of the experts on the panel have recent or current financial ties to drug makers. In addition, both the American Heart Association and the American College of Cardiology, while nonprofit entities, are heavily supported by drug companies. The American people deserve to have important medical guidelines developed by doctors and scientists on whom they can confidently rely to make judgments free frominfluence, conscious or unconscious, by the industries that stand to gain or lose.

The authors conclude that:

Patients should be skeptical about the guidelines, and have a meaningful dialogue with their doctors about statins, including what the evidence does and does not show, before deciding what is best for them.

I think Professor Redberg and Dr Abramson have done a great job of highlighting the issues with cholesterol management and the new guidelines. The reality is, statins are already probably massively over-hyped and over-prescribed, and it’s gratifying that Professor Redberg and Dr Abramson are seemingly able to see that by looking at the data and thinking for themselves. Many doctors, I think, could learn a lot from them.

References:

1. Abramson JD, et al. Should people at low risk of cardiovascular disease take a statin?

BMJ 2013;347:f6123