Doctors embrace new guides on statins



Pittsburgh cardiologists Wednesday welcomed new guidelines for managing cardiovascular health, saying the changes reflect advances in research, an important focus on prevention and a chance to better tailor treatment to the patient.

Under the new best practices, physicians would rely less on LDL, or bad cholesterol, numbers alone to determine who needs a statin drug to lower the cholesterol circulating in the blood.

Instead, the guidelines, released Tuesday by the American Heart Association and the American College of Cardiology, recommend statins for patients who meet profiles based on age, medical condition and other risk factors -- a change that could dramatically increase the number of patients nationwide taking the drugs to prevent heart attacks and strokes.

"The rationale is that we want to find the high-risk patients who will benefit the most," said J. Travis Wilson, a cardiologist with Allegheny Health Network and assistant professor at Temple University School of Medicine.

John Schindler, an interventional cardiologist at UPMC, said the guidelines followed the profession's rigorous scrutiny of literature on how to control cholesterol and an analysis of who benefits from statins and who doesn't.

"I think the writing committee got it right," Dr. Schindler said.

David Burkey, a cardiologist at St. Clair Hospital in Mt. Lebanon, said the changes will broadly leverage the power of statins. "The studies show, the lower the LDL, the better," Dr. Burkey said. A statin, he said, "works like you wouldn't believe."

According to the new guidelines, doctors should prescribe statins to:

• Patients with diabetes who are 40 to 75 years old.

• Those 21 and older with LDL levels of 190 or higher.

• People with a history of cardiovascular issues.

• Anyone who does not have cardiovascular disease but is 40 to 75 years old and has a 7.5 percent or higher risk for heart attack or stroke within 10 years, based on the new profiles, which, for the first time, incorporate race into risk assessment.

The guidelines -- the first in about a decade -- also give doctors more flexibility in developing treatment plans.

They do away with what doctors described as number-chasing -- trying to get patients' cholesterol down to prescribed levels, such as LDL of less than 70 for patients with certain histories of heart disease. Rather, the guidelines recommend that LDL numbers be reduced by certain percentages.

"That's a real novel approach, and what I like about it is, it's very patient-focused approach," Dr. Wilson said of the change, noting it allows the physician to customize a patient's treatment.

Dr. Schindler said the change will help physicians balance patients' cholesterol and medication tolerance. The drugs have been linked to a slight increase in risk of diabetes, and some patients complain of muscle pain and cognitive issues while taking them.

He said the change also reflects the profession's acknowledgment of a limitation -- it doesn't yet know the "exact magic number" for LDL. "Now, what we're saying is, based on the available literature, we don't really know what the goal should be."

Instead of managing cholesterol to particular levels, the guidelines focus on "defining subgroups of patients" for whom lowering LDL "would have great benefit," said Srinivas Murali, medical director of Allegheny Health Network's Cardiovascular Institute and governor of the American College of Cardiology for Western Pennsylvania.

Also released Tuesday were guidelines for managing cardiovascular disease through weight control, diet and exercise.

The recommendations pertaining to nutrition and exercise are unusually detailed and show the interdisciplinary aspects of cardiovascular health, including the need to involve dietitians and exercise physiologists in some patients' treatment plans, said Dr. Murali, who is president-elect of the American Heart Association's Allegheny Division.

The guidelines already have been embraced by a number of medical professional groups, and the National Institutes of Health will be asked to promote them, he said.

Nationally, the new guidelines, particularly those pertaining to statins, have been described as a controversial paradigm shift in treatment. But local doctors said the changes more likely portend a refinement, not a sea change, in approach at many practices.

Amish Mehta, a cardiologist at Jefferson Regional Medical Center, said physicians already consider a patient's medical conditions and other factors, in combination with LDL numbers, to decide whether a statin is needed. And he said doctors already talk to patients about diet and exercise.

Autumn Stewart, assistant clinical professor at Duquesne University's Mylan School of Pharmacy who also oversees clinical pharmacy services at Catholic Charities Free Health Care Center, Downtown, said some doctors likely have been following clinical trials on statins and already have moved to broader use of them.

She said the new guidelines "bring the implications from the trials into the mainstream."

Joe Smydo: jsmydo@post-gazette.com or 412-263-1548.


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