WASHINGTON—Criticism over new cholesterol treatment recommendations appears to be growing, judging by remarks made by cardiologists this week at the annual meeting of the American College of Cardiology, the group that issued the new guideline last November along with the American Heart Association.
Doctors are supposed to use the guideline to help them identify which patients without heart disease could benefit most from lifestyle changes or statins in order to prevent future heart attacks or strokes. But cardiologists complain that a new risk calculator tool — which takes into account age, race, gender, and heart risks such as high blood pressure and cholesterol — overestimates cardiovascular risks, especially in older Americans.
“I don’t know anyone who’s using it,” Dr. Rita Redberg, a cardiologist at UCSF School of Medicine, said during an interview at the meeting. “I still use the old Framingham risk score to assess heart attack risk.” (The latest version of Framingham is more than a decade old and doesn’t predict stroke risk.)
She and others are concerned that the new risk calculator tool will result in more healthy patients being unnecessarily put on statins to prevent heart disease. Brigham and Women’s Hospital researchers estimated that the risk tool overestimated heart risks by 75 to 150 percent in a paper published last fall in the journal Lancet. And a new Duke University analysis published last month in the New England Journal of Medicine predicted that the calculator tool would make 13 million more American adults eligible for statins, including 87 percent of men ages 60 to 75 and 54 percent of women in that age group.
“The tool puts a far greater percentage of Americans in the high-risk group for heart disease, but that implies a certainty that we don’t really have,” said Dr. Michael Blaha, a clinical research fellow at Johns Hopkins Heart and Vascular Institute, in a presentation he gave at the meeting. "In some ways, it’s a step backward because it puts so much reliance on age to assess risk.”
American College of Cardiology leaders insist that the tool works well and was validated to work before the guideline was published. “It so much improves our ability to predict risk,” said the College’s president-elect Dr. Kim Allan Williams. “It has more information on strokes, race, and gender” than previous risk calculation tools. While it may overestimate risk, he added, research suggests that those placed in the “high risk” group who are given statins wind up with fewer heart attacks and strokes than their counterparts who are not given the drugs.
But super-buff, kale-consuming baby boomers heading into their 60s may argue that their hearts are healthier than a smoking, out-of-shape 30-year-old’s. And they may be loathe to go on a statin just because their cholesterol numbers are a little high.
(While considered very safe drugs, statins slightly increase the likelihood of Type 2 diabetes and can cause severe muscle soreness that makes it difficult to exercise.)
That’s perfectly fine, said Dr. Neil Stone, the Northwestern University cardiologist who led the committee that authored the new guideline. “The risk estimator was designed to start a conversation,” he told me, not dictate who should go on statin drugs. “Patient preference is a very important part of this guideline, and we were very strong in emphasizing lifestyle changes over medication.”
He said he often discusses with patients not only the pro’s and con’s of statin therapy for prevention but also how much increasing physical activity and improving diet — to one based more on plant foods and less on animal products — can lower heart risks.
One dramatic example of this came from a patient case presented at the conference by Dr. Robert Ostfeld, a cardiologist at Montefiore Medical Center: A 40-something overweight man with high blood pressure and soaring cholesterol levels who couldn’t walk more than a few blocks without chest pain told Ostfeld that he didn’t want to take statins under any circumstances.
While cardiologists listening to the case at the conference insisted that the man should have been talked into going on the drugs, Ostfeld revealed that within a year after switching to a vegan diet, the man lowered his cholesterol levels and blood pressure to nearly normal, got his weight into a healthy range, and was jogging two miles — all without cholesterol-lowering medication.