Cholesterol Conversations

Feb 03, 2014 at 04:31 pm by Staff

New Guidelines Open the Door for Dialogue with PatientsWhile guidelines are meant to clarify best practices and offer a clear clinical path, sometimes changes wind up being more confusing … leading to debate over what truly is best for patients. The latter seems to be the case with four guidelines released by the American Heart Association (AHA) and American College of Cardiology (ACC) last November.A great deal of discussion has already arisen over new cholesterol treatment guidelines, which significantly change the threshold for starting a statin regimen. In answer to publicity focusing on the number of Americans who might now qualify for a statin prescription, AHA President Mariell Jessup, MD, said, “The goal is not to get more people on statins. The goal is to help Americans reduce their risk of cardiovascular diseases and stroke. The goal is to help people live longer.”No matter what the goal, local cardiologist David Huneycutt, Jr., MD, FACC, said the reality is that the new guidelines greatly expand the number of people now recommended for statin therapy. Huneycutt, a general cardiologist for Centennial Heart with a focus on prevention of cardiovascular disease, said the guidelines specify four groups for statin therapy:

Everyone with a history of cardiovascular events. People 21 and older who have a very high level of bad cholesterol (190 mg/dL or higher) People ages 40-75 with Type 1 or Type 2 diabetes. People 40-75 years old without cardiovascular disease who have a 7.5 percent or higher risk for having a heart attack or stroke within 10 years as determined by a downloadable risk calculator (located in the professional section of the AHA website as part of the 2013 prevention guideline tools).

“I think the biggest area of controversy is over the new risk calculator,” Huneycutt said. “This risk calculator is very different than the previous one.” He explained that physicians previously used the Framingham Risk Calculator, which had a higher threshold and harder endpoints for determining when to put a patient on statins. Huneycutt added age and gender carry great weight in the new calculator.“It’s really pretty easy to have a 10-year risk of more than 7.5 percent,” he said. “A man can be 65 years old with no other risk factors and still meet the threshold.” Huneycutt added, “If a physician is relying on the risk calculator alone to determine a patient’s need for a statin, then yes, we are going to see more patients on them.”He noted the new guidelines are a mixed bag with some steps that he thinks are positives for patients. Previously, Huneycutt noted, a patient with established coronary disease with an LDL of 85, which is 15 points over the target of 70, would have gone on a high-dose statin regimen or additional drug therapy. “More side effects occur in higher doses of statins or in combination with other medicines,” he pointed out. “While the new guidelines might increase the number of overall people who are candidates for statins, it might reduce some of the very high doses of statins and the addition of non-statin medications because you’re not treating to a numeric target.”Huneycutt’s frustration with the new guidelines is in the quickness to jump to a pill when other options are available. “Overall, I think we’re off track,” he said. “I think we use medications way too soon.” He continued, “I don’t think we should be having conversations around medications. I think we should be having conversations around risk modification. In the entire guideline, which is 85 pages, it has basically one paragraph about lifestyle modification. “It is a failing of these guidelines and the medical community. I think 90 percent of the conversation should revolve around nutritional counseling and lifestyle modification and 10 percent around drug therapy. Unfortunately, right now with the state of healthcare, it’s exactly opposite.”In counseling patients, Huneycutt said he encourages a healthy diet. “For me, that means a plant-based diet that includes vegetables, fruits, whole grains and beans and is devoid of animal products, highly processed foods and oils.” He recognizes this is a more aggressive diet than is recommended by the AHA. However, Huneycutt added, “In my clinical practice, many patients are able to reduce their risk factor profile without requiring drug therapy.” He said the nutrition recommendation is in combination with physical activity and is typically the first step he takes as part of primary prevention. Huneycutt was quick to add that he absolutely uses drug therapy when warranted but noted statins, like all medications, do have side effects … some significant. And, he continued, medication and lifestyle modification certainly aren’t mutually exclusive. “Many patients with established heart disease benefit from both. I like to try lifestyle modification first, when possible, making that the cornerstone of treatment,” he concluded.

For More on Nonpharmacologic InterventionsDavid Huneycutt, Jr., MD, a general cardiologist with Centennial Heart, fashions his practice around primary and secondary prevention of cardiovascular disease. Lifestyle modification plays a key role in his toolkit. He suggested a couple of resources for physicians or patients interested in learning more about the nutritional changes that can play a major role in keeping hearts healthy. “Forks Over Knives”: a 2011 documentary, directed by Lee Fulkerson, available on Netflix and YouTube.“Eat to Live: The Amazing Nutrient-Rich Program”: book by Joel Fuhrman, MD.

Sections: Archives