Under the old guidelines, the statin dose depended on how much it
took to get a person's blood cholesterol levels into a certain
Under the new guidelines, which were issued last year, once someone
qualifies for statin therapy, the dose should be determined by the
person's risk of cardiovascular disease and not according to how
cholesterol levels respond to treatment.
People in the highest risk group should be placed on the highest
statin dose. Someone in the lowest risk group should receive the
lowest dose of statins. And for people in-between, the dose of
statins should be in-between.
And once people are started on a statin, they’ll keep receiving the
starting dose regardless of how their blood cholesterol level
responds to treatment.
Even if they don’t have high levels of “bad” LDL cholesterol, they
might qualify for statin treatment if the new formula provided by
the guidelines indicates that they face a risk of at least 7.5
percent of having a cardiovascular event in the next 10 years.
“I think that initially both patients and physicians had a hard time
letting go of LDL cholesterol goals because the targets gave
something concrete to aim for," wrote Dr. William B. Borden, a
cardiologist at George Washington University in Washington, D.C. in
an email to Reuters Health.
"The new guidelines jettison those targets and focus on tailoring a
risk modification strategy specific to the patient,” he added.
“These recommendations are more evidence based and focus our
prevention efforts on what we know the best to work,” said Borden,
who supports the changes.
On the other hand, Dr. Scott M. Grundy from the University of Texas,
Southwestern Medical Center and VA Medical Center in Dallas, Texas,
believes cholesterol levels should still influence management.
Grundy wrote one part of a two-part critique of the guidelines
that’s scheduled to appear online in the Journal of the American
College of Cardiology.
“The new guidelines suggest when to start statins in patients at
risk,” he told Reuters Health by email. “The other perspective
offers a broader approach to cholesterol management that revolves
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“A lack of cholesterol goals leaves the physician in the dark for
setting an individualized statin dose and evaluating the adequacy of
the risk reduction from therapy,” Grundy said.
In his critique in the journal, he wrote that the new guidelines
don’t tell doctors “how to adjust the guidelines to best fit the
In the second part of the critique, Dr. Sidney C. Smith, Jr. from
the University of North Carolina School of Medicine in Chapel Hill
reviews the new guidelines and the research behind them. His
conclusion? Guidelines “inform, but do not replace” the doctor’s
judgment and experience.
Evidence from research must be combined with the doctor’s judgment
and the patient’s preferences, he said.
How patients and their doctors manage cholesterol will depend on the
individual patient's risk, their willingness to take statins and how
they both read the results of all the studies.
Regardless of what patients and their doctors think about statins,
the guidelines and the experts agree: “A heart-healthy lifestyle
remains the foundation for preventing (cardiovascular disease) and
must be part of all efforts to improve (cardiovascular) risk factors
Journal of the American College of Cardiology, online August 4,
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