[ed. note: We feature the writings of Doc Gumshoe, our favorite medical scribe, every few weeks here at Stock Gumshoe. He is not a doctor, but we value his insight, research, contrariness and skepticism … and, most importantly, his ability to explain complex health issues for our readers. You can see all of Michael’s previous commentaries here.]
By now nearly everyone has heard about these controversial new statin guidelines, announced on Tuesday, November 12, by the American Heart Association and the American College of Cardiology. In the event that you have been paying attention to far more important matters, such as whether Alex Rodriguez will ever play baseball again, I will briefly summarize the main points. And, to give you an advance peek at where I stand: no, I don’t go with the narrative that holds that this is a conspiracy by the AHA and the ACC to throw more business to Big Pharma. But, also, no, I emphatically don’t believe this is the best way to address the huge issue of interlinked cardiovascular diseases.
Here are the essentials of what these AHA/ACC guidelines do:
- They attempt to quantify total cardiovascular risk by arriving at a percentage figure for a ten-year risk of cardiovascular events (heart attack or stroke). Individuals aged 40 – 75 whose ten-year risk is 7.5% or higher are recommended to take statins.
- They recommend that persons whose LDL-cholesterol levels are 190 mg/dL or higher should take statins.
- The also recommend that persons with existing heart disease or Type 2 diabetes should take statins.
- But specific LDL-cholesterol goals are not part of the new guidelines.
- And regular monitoring of blood cholesterol levels is not necessary. The effects of treatment should not be based on how much cholesterol-lowering takes place.
There’s more, but those are the essentials.
As soon as AHA/ACC announced the guidelines, the fur began to fly. Many of the most eminent cardiologists in the country registered vigorous exceptions. One in particular, Dr Paul Ridker, of the Harvard Medical School, examined the algorithm used to calculate the CV event risk, and came to the conclusion that it tended to overestimate risks by a very large percentage, from about 75% to 150%. This would mean that some people would erroneously be placed in the category deemed to need statins when they probably did not need statins at all.
Another critic is Dr Steven Nissen, of the Cleveland Clinic. Dr Nissen did a couple of calculations in men who would be considered healthy by any usual standard – normal blood pressure, normal total cholesterol and HDL-cholesterol, not diabetics or smokers – and the algorithm in both cases (one African American, one white, both age 60) put their risk factors as 7.5%, therefore recommending statins for both men.
A specific criticism leveled at the risk calculator is that it is excessively quantitative – for example, it gives equal weight to a 30 point difference in systolic blood pressure, whether it’s between 100 and 130 mm Hg or 150 and 180 mm Hg. The risk calculator just factors in the number and spits out the answer.
And how about not monitoring cholesterol once the patient is started on the statin? Is the patient supposed to take it on blind faith that the statin is good for him or her? The AHA/ACC folks essentially say “yes – don’t just go by the numbers” (having put the patient on the statin by the numbers in the first place.) But if you’re the patient, what do you go by? In the opinion of many top cardiologists, this would result in low patient compliance, i.e., patients would just not take their pills. And, cardiologists will realize that and not follow the guidelines.
By the way, as these guidelines were being developed, the National Heart, Lung, and Blood Institute – the body that includes the National Cholesterol Education Program (NCEP) – took itself out of the picture. That should tell us something! NCEP has in the past issued treatment guidelines including guideline for statin therapy, and these guidelines have included risk assessment algorithms, i.e., the Framingham Risk Calculator. But those guidelines were much, much more conservative with regard to recommending statin treatment.
What I can say about the new guidelines is that they constitute an attempt to address the entire spectrum of cardiovascular disease (CVD). That’s one thing that I strongly agree needs to be done. Let’s take a look at the whole CVD spectrum.
Cardiovascular disease and homeostasis
Diseases, illnesses, maladies, disorders, conditions … whatever we call them, have origins that can be grouped under different headings. There are infections caused by invaders such as microbes, bacteria, viruses. There are the maladies caused by nothing more complex than wear and tear, suc