Cholesterol Guidelines: Annals of Internal Medicine Offers a Guide for the Perplexed — Physician’s First Watch

Medical News |
January 31, 2014

Cholesterol Guidelines: Annals of Internal Medicine Offers a Guide for the Perplexed

By Joe Elia

Edited by André Sofair, MD, MPH, and William E. Chavey, MD, MS

The guidelines on assessing cardiovascular risk and cholesterol levels that were released in November have not had a calming effect on clinicians, according to commentators. The Annals of Internal Medicine offers four articles meant to allay fears -- or at least provide some perspective. The articles include a synopsis of the guidelines.

Skeptical commentators argue that lowering the treatment threshold to a 7.5% 10-year risk will lead to overtreatment. (Other commentators argue that the ideal threshold may lie between 5% and 15%, given the limitations of the risk calculator, which is scheduled for revision in the coming months.)

From an even more practical standpoint, another group reminds clinicians that finding time for the patient discussions recommended in the guidelines will be difficult. The discussions might best be planned to occur over a series of visits, in their view.

An editorial sagely advises that readers "listen to the evidence, not the noise."

Reader Comments (8)

Jason Lambrecht Physician, Internal Medicine, Hospitalist

I understand some of the comments above, regarding financial issues, but I really don't understand the negative overtone to statin therapy. As a physician and hospitalitist, and a previous cardiac clinical pharmacist, I think we need to wait another 10 to 20 years before we see what statins do in patients that we use them in patients based on risk and risk factor estimates or for early primary prevention. As of right now, I have nothing more to offer patients for primary prevention and with over 500000 people dying of cardiac disease every year, I would rather offer a statin to my patient who is 40 or 45 with significant risk factors or concern for CAD then nothing. As a previous pharmacist on a cardiac unit, 15 years ago it was frustrating to see 55 or 60 year old patients undergoing PCI or CABG and no statin in their medication list. Statins have a tremendous amount of data about their efficacy and risk reduction. Please don't let the researchers' lack ability to pinpoint the EXACT variable(ie, LDL, non-HDL or whatever) which is modified by these drugs, lessen your future use of these agents. Our goal as internists is to prevent disease, statins have shown benefits both primary and secondary, to decrease CAD, PVD and stabilization of plaques, not to mention their ability to decrease inflammation and other disease modifying benefits. I understand your frustration with the guidelines, but the vagueness comes from the lack of our own insight into the TRUE cause of CAD. Statins, currently, are the only true way to lessen the risk of CAD. Please keep this in mind as you see your next patient, a 45 year old male with 2 young children, cholesterol of 240, lives a sedentary life, LDL is 175, BMI is 27, borderline high blood pressure, and have been talking about exercise, weight reduction and better eating habits for the last 10 years. Do you think he is at risk for CAD?...and we haven't even talked about his social or family history yet....

Mervyn Garrett MBBS Physician, Allergy/Immunology, Private

The effect of statin drugs has more to do with their control inflammatory mediators then the level of cholesterol. Excepting those particular metabolic cases how can a patient with a normal coronary vascular tree have over 90% block over a centimetre or less be due to a diffuse metabolic problem? I await somebody to respond.

Hazem A. Hamdy, M.D. Physician, Family Medicine/General Practice, Ottawa, ON

All of the practicing physicians use "a calculator" or a guidelines that a calculator is imbedded into it. Calculator or not, 40% of patient with MI don't have risk factors to predict Cardiovascular event. I believe that a new Calculator will not solve the problem and more statin is not the answer.

jim Other Healthcare Professional, Cardiology, office

Silly rabbit, trix are for kids - and it appears statins are for unicorns. With all the BILLIONS of dollars spent on 'research' industry sponsored and otherwise, the best recommendations are >> "hey practitioner...go with your gut..."

This whole statinology is a "Don Poldermans" fiasco

Kristian Kunz, MD PHD Physician, Nephrology, AURAL Strasbourg

Does not every person over the age of 45 have a 10 year risk for mortality >7.5 % ?

McConnell, Lila Physician, Internal Medicine, Private Practice

I think Overdosed America by John Abramson offers great insight into our broken system. Personally, I resent being pushed into a "treat by numbers "
paradigm. Especially in primary prevention, as we all know, other risk factors must be taken into account
before relying on a " calculator" to prescribe. I wonder if down the road the "cholesterol hypothesis"
and the contribution to cardiovascular disease might
be more openly challenged if and when financial incentives begin to ebb.

SHELDON BALL Physician, Geriatrics, Anvita Health

I think we cannot rest assured that any revised guidelines, risk calculators, and recommendations will be free from influence of financial incentive. Financial incentive is a powerful motivation. I don't recall any evaluation of the implications for financial gain in the new recommendations.

Vince Miraglia Other, Other

The most severe problem here as mentioned in the Journal was that the calculator appears to consistently overestimate risk , The fact that many of the group devising the guidelines may have had conflicts of interest ; these guidelines will certainly increase sales what net effect they will have on health is yet to be determined.

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