New Guidelines on Managing Cardiovascular Risks Show a Significant Shift in Focus
In November 2013, the American Heart Association and American College of Cardiology released new guidelines on management of cardiovascular risks that herald a new approach, with less emphasis on cholesterol numbers and more emphasis on the constellation of factors that determine a person’s risk of heart disease, heart attack and stroke.
“The new guidelines are meant to simplify treatment of cardiovascular risks; they call for assessing overall risk, then enacting therapy based on whether your risk is high, moderate, or low. The previous guidelines called for assessing the risk, basing the target goal for LDL cholesterol on that risk, and then attempting to reach that target. In the new guidelines, the LDL goal is eliminated,” explains Robert J. Kim, MD, cardiologist and associate professor of clinical medicine at Weill Cornell Medical College.
Assessing risk
At the heart of the new guidelines is a risk assessment tool that takes into consideration your age, gender, race, total cholesterol, HDL cholesterol, systolic blood pressure, blood pressure treatment, diabetes, and whether you smoke. When this information is entered into a calculator, your 10-year risk and lifetime risk (if your age is lower than 60) for heart attack and stroke can be determined. You can calculate your own risk online at http://my.americanheart.org/cvriskcalculator.
The guidelines call for a person with a 7.5 percent or higher risk for heart attack or stroke to be treated with statin drugs, which include simvastatin (Zocor), atorvastatin (Lipitor), rosuvastatin (Crestor), and lovastatin (Mevacor). They also recommend treatment for people with known heart disease, hereditary cholesterol elevations, and diabetes.
New guidelines under fire
In response to the new guidelines, some health experts have expressed concerns that people who were previously considered to be at low risk for heart disease and stroke will have a higher risk with the new assessment tool, which could lead to millions more Americans being treated with statins. The members of the expert panel who created the guidelines acknowledged the possibility of overestimating risks in some populations and said they will continue to evaluate the risk assessment methods and make changes if any are warranted.
However, Dr. Kim notes that taking a statin isn’t mandatory, regardless of your risk: “Every patient needs to have a conversation about their cardiovascular risks with their doctor; it is a personal decision based on multiple variables. Some patients are OK with taking a pill every day to lower their cardiovascular risk; some are not.”
He also mentions that, overall, statins are very well tolerated, but some patients have problematic side effects, including myalgia (muscle aches) and cognitive dysfunction (memory loss and/or confusion), which typically stop when the statin is discontinued.
Beyond statins
Notwithstanding the guidelines’ emphasis on statins, Dr. Kim notes that lifestyle strategies to decrease your risk should always be considered first.
“You can unequivocally lower your cardiovascular risk with diet, exercise, and weight loss or management as much as you can by taking a statin. The lifestyle choices also have many other benefits on your cardiovascular system,” he emphasizes.
However, he acknowledges that adopting a healthy diet and exercising regularly are difficult for many patients. Dr. Kim says it can be extremely helpful to consult with a physical therapist and a registered dietitian who can tailor exercise and dietary programs to your individual needs and preferences. Most insurance covers these services if you have certain diagnoses, such as diabetes or chronic kidney disease, but for people without these diagnoses, they are often not covered.
Your individual risk
Dr. Kim cautions against putting too much weight on what the new guidelines say about your risk.
“The risk assessment tool is not a crystal ball. It provides an estimate of the risk of a broad popula-tion with similar characteristics to a given patient, but it can never give an individual’s personal risk. And risk assessment of this type will always be imperfect, given the large number of variables that can come into play,” he says.
The guidelines also mention other factors that may be considered when making treatment decisions: family history, high-sensitivity C-reactive protein (a marker of inflammation), coronary artery calcium score, or ankle-brachial index (a measure of blood flow in the extremities).
What it all means to you
The bottom line, according to Dr. Kim, is that “you are not a number. Your individual factors and preferences need to be discussed with your doctor when determining how to best manage your cardiovascular risk. However, the new guidelines have defined risk categories in such a way that, if you are at risk, it is now easier to determine the drug therapy that is appropriate for you.”
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