Earlier this week, the American College of Cardiology/American Heart Association (ACC/AHA) released long-awaited updates on guidelines for managing high cholesterol. In addition, they simultaneously released three other guidelines – on heart disease prevention, management of obesity, and on risk stratification for cardiovascular disease. These guidelines are definite steps in the right direction. For example, the new cholesterol management guidelines have done away with treating LDL cholesterol to specific “numbers” (such as less than 70 mg/dL in those with known cardiovascular disease, and less than 100 mg/dL to prevent the first event in those without known disease), and have adopted a more “individualized” approach to treatment with moderate-intensity (medium dose) or high-intensity (high dose) statin drugs.
Along these lines, four risk groups have been identified that might benefit the most from statin therapy – those with known cardiovascular disease, those with LDL cholesterol >190 mg/dL, those with diabetes and no known disease in the age range of 40-75 years with LDL cholesterol anywhere between 70 and 189 mg/dL and those with estimated 10-year risk of clinical cardiovascular disease of >7.5%. The general recommendation is to use the maximum dose of statin drugs that an individual patient may tolerate, to achieve LDL levels that may be optimum for them. For example, the lowest LDL level that someone with known disease is able to achieve on the highest dose of statins may be optimal for them. The new guidelines specifically discard the notion of using additional non-statin drugs just to get the LDL “number” lower, since no big study has definitely proven the additive value of such an approach.
These guidelines also make an attempt to incorporate the use of imaging data in decision-making, albeit minimally. The recommendation is to possibly treat individuals with calcium scores >300 Agatston units with intermediate-to-high intensity statins. Alarmingly, in this recommendation, the guidelines miss an important lesson learned from the vast wealth of cardiac calcium scoring studies – any calcium in the coronary arteries confers a higher risk of downstream events, not just >300 Agatston units.
Unfortunately, the most important factors in prevention and management of cardiovascular disease have been somewhat glossed over in these new guidelines – lifestyle changes. By emphasizing the use of statins (which are not benign in terms of side effects), the guidelines are indirectly broadcasting the message of licentiousness for those variables that cause the majority of heart disease – lifestyle choices. The prevention guidelines effectively consolidate lifestyle choices into eating right and exercising. However, in my own cardiology practice, I have not come across one patient who does not already know this. Yet, knowing what to do and actually doing it are two different things. Unfortunately, most doctors simply do not have the time or the motivation to inspire meaningful lifestyle changes in their patients. And to inspire such changes would require delving deep into the patient’s psyche to discover what prevents them from adopting healthful changes. There are innumerable reasons for not being able to adopt right choices – psychosocial stress, depression, other concomitant chronic illnesses and so on. From the provider’s perspective, it is far easier to write out a prescription than spend time talking or counseling, a behavior that might potentially be reinforced with these new guidelines favoring drug therapy in an already prevalent “pill popping” culture.
Heart disease is a disease of lifestyle. And largely preventable. In the rapidly changing landscape of the practice of medicine, it would serve us well to focus on prevention – as in making the time and effort to help our patients make meaningful changes “from within”. And that would mean spending enough time and effort to alleviate their unique stresses and blocks that prevent them from doing what they need to do, instead of adopting the approach of a “blanket” statin prescription for all. This is true personalized medicine.