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May 01, 2014

The New Cholesterol Treatment Guidelines: Heart Disease and Strokes Matter

Doctors and researchers do not all agree on who should take statins, and the debate boils down to the importance of preventing heart attacks and strokes.

Under the recent American College of Cardiology (ACC)/American Heart Association (AHA) cholesterol treatment guidelines, more people will qualify for treatment of their cholesterol with medications called statins in addition to working on healthy diet and lifestyle changes. This recommendation is based on many years of careful research showing that taking a statin can help to prevent heart attack, stroke, and blockages in other arteries. In addition, statins can prevent deaths due to heart disease. These benefits are seen even in people who are not at high risk for these life-altering problems. However, there are still doctors, researchers, and others who think that the new guidelines went too far. They argue that statins probably do more harm than good in all but the most high-risk people. A large part of this disagreement boils down to what medical problems each group thinks are important to prevent.

When designing a research study of a medication, the researchers need to decide what effects (called “outcomes”) of the medication are important. To decide, they consider what benefits of a drug would make it appealing to patients and doctors. These include clinical outcomes like fewer heart attacks and strokes, or longer life. In addition, they must also keep careful watch for side effects of the drug. (A drug that prevents heart attacks but causes more deaths would certainly be a drug that should not be used.) The research study then gives the drug to one group of patients but not to another group. At the end of the study, the important outcomes (like heart attacks, muscle aches, and forgetfulness) in each group are compared to each other. If the benefits of the drug outweigh the side effects, the study was successful and the drug can be recommended for use in patients similar to those who were in the study.

The main question, then, is what benefits and risks are important? This is where there is a lot of disagreement about research studies for statins. Some people think that the only important benefit for patients who are at risk for heart disease is fewer deaths from any cause (for example, from heart attacks, car accidents, old age, and others).  They agree that statins decrease deaths from heart-related causes. However, they reason that if this doesn’t translate into fewer deaths from any cause, there may be a side effect that is causing more deaths. They think this is the only way deaths from any cause could be unchanged. In addition, they think that fewer heart attacks, strokes, and deaths from heart disease are not important enough to be a reason to prescribe statins.

The expert panel that reviewed all of the excellent-quality research studies about statins and wrote the recent ACC/AHA cholesterol treatment guidelines disagreed with this argument. There is no doubt that people who take statins have fewer deaths from heart disease, heart attacks, strokes, and blockages in other arteries than those who don’t take statins. A heart attack or a stroke can be life-altering, and taking care of the long-term medical problems these cause is very expensive for the individual and the health care system. Therefore, although preventing death is important, we shouldn’t throw away a therapy that can prevent many important medical problems and death from heart disease just because it doesn’t prevent death from any cause. In addition, the side effects of statins are generally uncommon, and all of the more common side effects (muscle aches and pains) go away when the statin is stopped. Therefore, people who are at moderate to high risk for heart disease and strokes should talk with their doctor to decide if taking a statin, in addition to a healthy lifestyle, is right for them.

Authors: Matthew Czarny, MD and Roger Blumenthal, MD



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