Reena Pande, M.D.

Cholesterol and statins: it’s no longer just about the numbers

Updated cholesterol guidelines released yesterday by the American Heart Association and American College of Cardiology aim to prevent more heart attacks and strokes than ever. How? By increasing  the number of Americans who take a cholesterol-lowering statin.

The previous guidelines, published in 2002, focused mainly on “the numbers”—starting cholesterol levels and post-treatment levels. The new guidelines focus instead on an individual’s risk of having a heart attack or stroke. The higher the risk, the greater the potential benefit from a statin.

Statins are a family of medications that lower cholesterol. Even more important, they lower the chances of having a heart attack or stroke. Statins include atorvastatin (generic, Lipitor), fluvastatin (generic, Lescol), lovastatin (generic, Mevacor), pitavastatin (Livalo), pravastatin (generic, Pravachol), rosuvastatin (Crestor), and simvastatin (generic, Zocor). The new guidelines recommend a statin for:

  • anyone who has cardiovascular disease, including angina (chest pain with exercise or stress), a previous heart attack or stroke, or other related conditions
  • anyone with a very high level of harmful LDL cholesterol (generally an LDL above greater than 190 milligrams per deciliter of blood [mg/dL])
  • anyone with diabetes between the ages of 40 and 75 years
  • anyone with a greater than 7.5% chance of having a heart attack or stroke or developing other form of cardiovascular disease in the next 10 years.

How is this different from the previous guidelines? They recommended specific cholesterol targets for treatment. For example, people with heart disease were urged to get their LDL cholesterol down to 70 mg/dL. The new guidelines essentially remove the targets and recommend basing treatment decisions on a person’s heart risk profile.

In other words, anyone at high enough risk who stands to benefit from a statin should be taking one. It doesn’t matter so much what his or her actual cholesterol level is to begin with. And there’s no proof that an LDL cholesterol of 70 mg/dL is better than 80 or 90 mg/dL. What’s important is taking the right dose based on heart attack and stroke risk.

There are a few reasons for these new “risk-focused” guidelines:

  • Statins are the best drugs to lower LDL cholesterol.
  • Statins also have benefits above and beyond cholesterol lowering. We have long known that statins lower the risk of premature death, heart attack, and stroke, even among individuals with relatively normal cholesterol levels—who are not exempt from having heart attacks or stroke.
  •  A statin dose tailored to the individual appears to be more important than reaching a particular target number.

Putting guidelines into practice

Will these guidelines change how your doctor checks and treats your cholesterol? Yes and no. Many physicians are already focusing on the balance of benefits and risks when making decisions about treatment. I, for one, am already prescribing statins to patients of mine at high risk of heart disease even when their cholesterol levels are close to normal. What will be new for me is making sure my patients are on an effective dose and no longer focusing on how low their LDL drops.

These new guidelines, while meant for doctors, contain a lot that each of us can do. Here are some examples.

  1. Go beyond the numbers. When talking with your doctor, instead of focusing on your cholesterol “number,” ask about your risk for developing cardiovascular risk. That appears to be a better guide as to whether you should be on a statin. Your doctor should have tools to help you estimate that. The new AHA/ACC guidelines recommend replacing the Framingham Risk Score with a new way to estimate risk.
  2. Consider the risks. No treatment is without some risk. Statins can cause muscle pain, and in a small number of individuals, more significant muscle injury and rarely liver problems. They have also been associated with increases in blood sugar, which in some cases leads to a diagnosis of diabetes. Some reports have linked statin use to memory issues, but the evidence is unclear. In the end, it’s a matter of balancing the low risk of these side effects with the potential benefit of lower risk of heart disease, stroke, and death. Have an open conversation with your doctor to consider your personal benefits and risks.
  3. Remember the other stuff. These new guidelines are quick to remind us that there is more to lowering cardiovascular risk than just taking a statin. We need to remain focused on living healthy as well—eating right, getting exercise, not smoking, and maintaining a healthy weight.

Other guidelines released this week—assessing cardiovascular risk, lifestyle management to reduce cardiovascular risk, and management of overweight and obesity in adults—can help us do this.

Related Information: Harvard Heart Letter

Comments:

  1. Thomas Davis

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  2. David R

    And what evidence is there that these drugs lower risk of heart attacks or stroke? Absolutely none, other than the anecdotal belief that lower “cholesterol” is better.
    And in fact the people who end up getting joint replacement surgery due to side effects of joint pain are at thousands or more times more risk of dying.

  3. William

    The information is very helpful. ..although I knew this already, the article provides more details. My question is this, just having high cholesterol levels, is this considered having heart disease?

  4. Richard Tew

    Is there a limit to how low LDL can be safely lowered? Can the LDL get ‘too low’, raising risk of other problems? (I see mention elsewhere of mood disorders, hemorrhagic stroke, even cancer.) Am particularly interested in this question in male > 60 yo with history of Hypertension (controlled with multiple meds), History of stroke (never established whether hemorrhagic or thrombotic), and treatment (seemingly well tolerated) with statin so LDL < 40.
    How is too low? Is any low value OK? Do we have evidence based medicine to support claims of safety of very low LDL levels?
    Thanks for any response.

  5. Oshme

    Thanks for your information..Its very useful to all..America! Research why your Cholesterol levels are elevated! What do the standard tests really show? They are using old tainted clinical trial. You’d be surprised at what really raises your cholesterol!

  6. Obat Kencing Nanah

    tang your all information..

  7. Paul Johnson

    Thanks

  8. Barry Collier

    Read ‘The Great Cholesterol Myth” before starting use of statin drugs. Cholesterol is not the problem when it comes to heart disease. Yet the use of harmful statin drugs persists. The side effects of statins do not out weigh the benefits. Proper diet and exercise are far more beneficial and produce no side effects. It seems that cholesterol reducing statins are treating a “problem” that doesn’t need to be treated. In fact, cholesterol has many benefits and is necessary for the human body to function properly. This is a complex issue and there seems to be many opinions on statin drugs. Read the book before making any decisions about statin use. It was very beneficial to me.

    • Robert Bramel

      Barry, you are so right! As a data point, I’m a 67 year old male with FH, my serum cholesterol has been over 600 for the last 6 years and my LDL is currently 517, yet I have zero !! coronary plaque by EBCT. rarely in the last 50 years has my total C been below 300, even when taking maximal meds. My last stress ultrasound showed my heart was I decades younger than 67 even though I’m not an exerciser. The experts, including Dr. Freeman of Harvard, have no explanation for any of this and as nearly as I can tell, no interest. Mostly I’m told that I’m at grave risk if I don’t get my levels down, but since stopping all meds six years ago, my muscle strength has vastly improved, my mental sharpness jumped (ask my wife) my “pre-diabetes” abated, and my LDL particle size is almost off-scale large (i.e., non-atherogenic).
      I just read an abstract of a study that tried to locate the “atherogenic lipid profile” as to whether it is located within the LDLR segment. Conclusion was it is not! No surprise here.

  9. Gary Clements-Diabeticareonline.com

    I am with your other respondents who are deeply concerned about the easy of Prescription drugs, over genuine lifestyle change for better health.
    Clearly for Diabetics, with a heightened risk of cardiovascular disease the chance of further increasing blood sugars makes these guidelines far from helpful.

    Lets get back to personal responsibility and healthy diet choices

  10. William

    Great article

    • whydopeoplecommitsuicide.com

      Great article. Health is wealth. Lot of people tend to lose their mental stability and induce suicide if the health is not taken care by doing constant workout and food habits.

  11. Live In Care Worker Jobs

    Great article
    I will put it in mind

  12. Jeanae

    I am a diabetic with Type 2 Insulin-Dependent. My HDL is 67 & My LDL is 128 but my Triglycerides are 255. Total Cholesterol is 246. I had really high LDL & low HDL until I started taking Coconut Oil capsules and also cooking with it. I made no other dietary changes at that time. I was having problems with Blood Sugar Control but that is resolving also. Do you think that the Coconut Oil is what is helping? I took it because I heard it would help with arthritis.

  13. arlene corwin

    Statins led directly to a muscle weakness and leg pain so dire, I, a naturally muscular woman could not get up from a squat position. I took a break. Came back a year or so later normalized, but with a high LDL. Started taking a new statin, but this time tried taking them every other day( instead of daily). I sensed muscular weakness again. Now I’ve stopped altogether.
    I’m 79, teach a yoga class, attend a gym class once a week, eat as an intelligent and informed eater should, but drink coffee; sit at my computer several hours a day. What now?
    It’s in the lap of the gods and my genes perhaps.

  14. Dr. Andrew Wojcicki

    I have not seen such disregard to very potential side effect of statin in producing this guideline. Where is molecular medicine, where is the role of CoQ10 in ATP to ADP , cycle of Krebs ,Cataracts, Demantia DM, kidney Failure, mayophaty including cardiac is more than enough to stop this statistical madness. Pfizer stock up from23.55 to 31.87!!!

  15. Sherry

    I am 55 and have very high LDLs. I have CAD. Statins lowered my cholestrol significantly. However, after a number of years my liver was damaged (it healed itself!) Now I am trying other col lowering meds with very little success. I am on three now. I will continue to eat healthy, exercise, and try to enjoy life, as I beleive these are my best medicines.

    • Ben Jensen

      You have a similar situation to me. I actually had a heart attacks before statins. Started statins, but stopped because the muscle aches prevented me from exercising. Really uncomfortable.

      My physician (Mayo Clinic), recommended a food alternative called StepOneHeart. See steponeheart.com. Lowered my LDL, by 50 points after going off statins. Feel great. Actually lost weight too. Try the chocolate crunch bars. I eat one everyday.

      Ask you physician about it. If you email them, Dr. Klodas will actually respond to you if you have questions.

  16. Constance Golden, RD,LDN

    Why are we so quick in this society to prescribe medicine over a healthy lifestyle? Why not focus on a healthy diet and exercise first before we jump into prescriptions with their inevitable side effects? Answer: because it is hard work and takes commitment vs. easy and immediate.

  17. Alice McElroy

    Most of the above information in this Harvard Health Blog relating to cholesterol and heart health is incorrect. The side-effects from statins are awful. Statins bring about Alzheimers, dementia, problems with memory, erectile dysfunction, low testosterone. The American Journal of Cardiology found that statin medications actually increased the risk of death. More information regarding cholesterol and heart health, with scientific studies can be found in the book Grain Brain by David Perlmutter, M.D. I highly recommend this book to anyone who wants a more accurate picture about heart health, cholesterol, statins, inflammation,brain health and much more.

    • Harvey Grove

      You can believe what you want, however, the majority of EXPERTS AGREE that statins are beneficial. You do not have to take them if you prefer, but I do not think you can convince many to go along with your rants about side effects. Lipitor has already been PROOVED to lower risk and and incidence of heart attacks and stroke. There is a joke among doctors that they should be added to drinking water. (THAT IS ONLY A JOKE. IT WOULD NEVER HAPPEN because ALL DRUGS HAVE SIDE EFFECTS, consequently, some people would have them and some can be serious. That is why they are prescription drugs as opposed to OTC (over the counter) products. When it comes to numbers (lab results) of your LDL or HDL my doc says,”I do not treat numbers. I treat patients”.

      • Mary Lefferman

        Yes! Statins seem to be weird medicine….People I saw before taking statins had only one problem – medium to high cholesterol levels but after taking them for awhile they seem to become very forgetful. I’ve seeing a lot of my clients in statins for quiet while and most of them are taking up to ten or more different medication to counterbalance the effects of statins. I noticed that must of them have totally change their personalities due to different effects of Statins and the added drugs to it.

  18. Kurt Housh

    Just keep in mind that all science is incomplete, or completely wrong.

    Ten years from now how will the medical community respond to this issue? In 50 years this will look like a treatment from the dark ages.

    Grandma was always right, eat your vegetables, get plenty of rest, and go outside and play. Oh and avoid anything with Monsanto corn in it, like American beef.

    • Montanette Bennett

      I agree totally with your comments. Thank you.
      More insight, wisdom is necessary to run our life . Eating healthily , cooking more to know what contains our food, practicing mindfullness to be able to enjoy the present moment instead of letting our thoughts run in all directions creating a fearful, stressful ,pointless life.
      Taking time to listen to the music of the soul and taking our strength in the silence between the thoughts. And most of all to be loving and compassionate to ourself and the world around us.
      Montanette

      • Carmen

        Totally agree with all your comments. I have high LDL but my HDL is the saving factor. I also eat healthily and have plenty of exercise. My blood pressure is perfect – there is a reason my body produces more cholesterol than I am getting through food. I feel safe and healthy. My partner had sleepless nights, night twitches and didn’t do well on cholesterol reducing drugs. He has stopped taking them and has made considerable life-style changes and he feels great.
        If people could listen to their bodies,try to make small lifestyle changes,care more about themselves and work together to improve the world and their surroundings we may eventually establish the true factors of cholesterol

  19. Dr. Stephen Sinatra

    While many aspects of these new guidelines concern me, one of the biggest is the concerns I have is the recommendation to use statin in people with diabetes. First off, statins can actually contribute to type 2 diabetes. In fact, last year the FDA began requiring statin manufacturers to put a diabetes warning on their labels. So giving statins to people who already have diabetes doesn’t make sense.

    Plus, the data demonstrates that for men with diabetes statin drug use can lead to calcification of the coronary arteries. There’s also documented evidence that cataracts are more common in those taking statin drugs. And since people with diabetes are already more prone to cataracts, the use of statins for this population can be harmful.

    A far better intervention for people with type 2 diabetes, or pre-diabetes, is lifestyle changes—including diet therapy; weight reduction; avoidance of sugars; exercise; use of raw foods, particularly vegetables; and targeted nutritional supplements.

    Dr. Stephen Sinatra
    Board Certified Cardiologist
    Assistant Clinical Profession, Connecticut University School of Medicine