Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

The new cholesterol guidelines: Emphasize patient preference

James McCormack, PharmD and Mike Allan, MD
Conditions
December 7, 2013
Share
Tweet
Share

There has been much discussion recently, by journalists and health professionals, on the new guidelines for the treatment of blood cholesterol put forward by the American Heart Association (AHA) and the American College of Cardiology (ACC).    Critics have raised concerns the revised guidelines will increase the number of healthy people who take statin drugs by 70 percent, that treatment thresholds are too low and that some guideline writers have links to the drug industry.

But these discussions have largely missed two key words in the new guidelines: “patient preference.”  The ACC/AHA state clearly, and emphatically — the term is used more than 20 times in the document — that this is a framework for clinical decision making that must incorporate “patient preferences.” To put this into context, the Canadian Cardiovascular Society lipid guidelines from 2006 and 2009 make no mention of patient preferences whatsoever, and while their 2012 version contains the word “preferences”  five times, only once do they actually refer to patient preferences.

This is an important transformation in guideline attitude, and here’s why.  No matter what recommendations this guideline or a health care professional may make, the patient is the one who should decide what’s best.

The biggest limitation of the ACC/AHA guidelines is that they don’t provide information in a manner that easily facilitates a balanced discussion between a patient and a health care professional.  Fortunately, it’s not all that difficult.

One of the most controversial parts of the guidelines is the threshold for treatment they recommended — individuals with a 10-year heart attack and stroke risk of 7.5 percent or greater is where “risk reduction benefit clearly exceeds the potential for adverse effects.” That’s their opinion but what counts is your opinion.

The evidence suggests statins reduce heart attack/stroke risk by approximately 30 percent or roughly 1/3.

What does this mean?  If you take roughly a 1/3 off of 7.5 percent (2.5 percent), the risk for heart attack and stroke would drop to around five percent. Put a different way, this means 40 people need to be treated for 10 years to benefit one person; or 97.5 percent get no clinical benefit whatsoever from statin drugs.

Let’s say a higher threshold like 10 percent had been chosen instead, as some critics have argued should have been the case. Doing similar math, 10 percent goes down to seven percent  (a 30 percent reduction) which is a difference of three percent.  Thus, 33 people need to be treated to benefit one person and 97 percent get no benefit from taking statins.  So the big debate about the threshold is a debate about a 0.5 percent 10-year difference (a three percent vs. a 2.5 percent benefit).

Now on the other end of the risk spectrum, a person with a past stroke/heart attack or an older person with many risk factors may have roughly a 30 percent risk. They would get a 10 percent absolute benefit over 10 years. This means this higher risk person (who has already had a heart attack or stroke) taking a statin for 10 years has about a one in 10 chance of benefiting from the medicine while 90 percent will get no benefit at all.

That’s the benefit, so what about harm?

Muscle aches and stiffness occur in five to 10 per cent of people taking statins, with severe muscle or kidney damage occurring in roughly 1/10,000, and possible abnormal liver lab values in two percent.  Some people experience nausea, constipation, diarrhea, and then, of course, there is the drug cost and the frustration of taking a pill every day.  Fortunately most of these harms are reversible.

There are a few caveats. Most studies with statins have been for five years or less, so we really don’t know about long-term benefit and harm.  You may have also heard statins cause diabetes, but the risk increase for diabetes is only about one percent, and because statins overall reduce the risk for heart attack or stroke (the reason we treat type 2 diabetes), this risk is not clinically important.

If, after thinking about the above information you wish to try a statin, then that is the right choice for you.  If, however, you don’t want to take a statin based on the information, that is also the right choice for you.  In either case, you can always change your mind.

ADVERTISEMENT

Your health care professional should support you no matter the decision. This is really what the new guidelines should be all about.

James McCormack is a professor, pharmaceutical sciences, University of British Columbia, Canada.  Mike Allan is an associate professor, department of family practice, University of Alberta, Canada. They both co-host the Best Science Medicine Podcast.

Prev

Doctors: 10 lessons from the humble bumblebee

December 7, 2013 Kevin 4
…
Next

Speakers need to explicitly state financial relationships

December 8, 2013 Kevin 15
…

Tagged as: Cardiology, Medications

Post navigation

< Previous Post
Doctors: 10 lessons from the humble bumblebee
Next Post >
Speakers need to explicitly state financial relationships

ADVERTISEMENT

More in Conditions

  • Why medicine must stop worshipping burnout and start valuing humanity

    Sarah White, APRN
  • Why perinatal mental health is the top cause of maternal death in the U.S.

    Sheila Noon
  • A world without vaccines: What history teaches us about public health

    Drew Remignanti, MD, MPH
  • Unraveling the mystery behind one of the most dangerous pregnancy complications: preeclampsia

    Thomas McElrath, MD, PhD and Kara Rood, MD
  • How community paramedicine impacts Indigenous elders

    Noah Weinberg
  • Pain is more than physical: the story your body is trying to tell

    Katie Hatt, DO
  • Most Popular

  • Past Week

    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • How community paramedicine impacts Indigenous elders

      Noah Weinberg | Conditions
    • Why Canada is losing its skilled immigrant doctors

      Olumuyiwa Bamgbade, MD | Physician
    • How to speak the language of leadership to improve doctor wellness [PODCAST]

      The Podcast by KevinMD | Podcast
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • How medical culture hides burnout in plain sight

      Marco Benítez | Conditions
  • Recent Posts

    • Why Canada is losing its skilled immigrant doctors

      Olumuyiwa Bamgbade, MD | Physician
    • Why doctors are reclaiming control from burnout culture

      Maureen Gibbons, MD | Physician
    • Would The Pitts’ Dr. Robby Robinavitch welcome a new colleague? Yes. Especially if their initials were AI.

      Gabe Jones, MBA | Tech
    • Why medicine must stop worshipping burnout and start valuing humanity

      Sarah White, APRN | Conditions
    • Why screening for diseases you might have can backfire

      Andy Lazris, MD and Alan Roth, DO | Physician
    • How organizational culture drives top talent away [PODCAST]

      The Podcast by KevinMD | Podcast

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 23 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • How community paramedicine impacts Indigenous elders

      Noah Weinberg | Conditions
    • Why Canada is losing its skilled immigrant doctors

      Olumuyiwa Bamgbade, MD | Physician
    • How to speak the language of leadership to improve doctor wellness [PODCAST]

      The Podcast by KevinMD | Podcast
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • How medical culture hides burnout in plain sight

      Marco Benítez | Conditions
  • Recent Posts

    • Why Canada is losing its skilled immigrant doctors

      Olumuyiwa Bamgbade, MD | Physician
    • Why doctors are reclaiming control from burnout culture

      Maureen Gibbons, MD | Physician
    • Would The Pitts’ Dr. Robby Robinavitch welcome a new colleague? Yes. Especially if their initials were AI.

      Gabe Jones, MBA | Tech
    • Why medicine must stop worshipping burnout and start valuing humanity

      Sarah White, APRN | Conditions
    • Why screening for diseases you might have can backfire

      Andy Lazris, MD and Alan Roth, DO | Physician
    • How organizational culture drives top talent away [PODCAST]

      The Podcast by KevinMD | Podcast

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

The new cholesterol guidelines: Emphasize patient preference
23 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...