New statin guidelines prompt praise, questions

New guidelines that could sweep as many as a third of all U.S. adults into being prescribed cholesterol-lowering statin medications have prompted plaudits but also questions among doctors regarding who should take the drugs -- and why.

The guidelines -- the first in a decade -- de-emphasize the importance of specific target levels of so-called bad cholesterol and highlight instead the importance of overall cardiovascular risk factors.

But some doctors worry about moving away from targeted cholesterol levels, a time-honored guide for more than 20 years.

"I am a little concerned that they've taken away a goal number. When you're talking about a specific percent reduction, you are basing your recommendations to patients on something tangible," said Dr. Louise Spadaro, a cardiologist at St. Francis Hospital in Flower Hill. She said she wondered, without a specific target, how seriously some patients would follow recommended measures.

"I do like that these guidelines take into account many of the steps we have followed all along," Spadaro added, referring to aggressive ways to lower risks and use of statins to lower cholesterol.

The new advice dissuades statin use based on cholesterol level alone, but suggests that possibly as many as 44 percent of men and 22 percent of women would meet the panel's baseline for a prescription. Only 15 percent of adults meet current statin guidelines.

Key among recommendations announced Tuesday by the American Heart Association and the American College of Cardiology is a broader use of statins, which inhibit a key enzyme linked to cholesterol production in the liver.

Well-known statins include Lipitor, Crestor and Pravachol. Statins have wide-ranging positive effects on plaque and cholesterol, which have made many doctors ardent supporters of their use.

Dr. Evelina Grayver, director of the coronary care unit at North Shore University Hospital in Manhasset, sees the new guidelines as a game-changer because the emphasis is on reducing atherosclerotic disease -- and statins help achieve that goal.

Atherosclerosis is marked by the formation of plaque in the arteries. Some plaque is stable and has a protective calcified cap, but some plaque remains uncapped and potentially dangerous.

Bits of unstable plaque can fracture and block a coronary artery, leading to a heart attack; or they can block a carotid artery to cause a stroke. Statins, Grayver said, can secure unstable plaque.

"I actually like these guidelines because they truly do focus on atherosclerotic events," Grayver said.

Dr. Suzanne Steinbaum, a cardiologist at Lenox Hill Hospital in Manhattan, also lauds the guidelines because of the new algorithm for highlighting those in need of statin therapy.

Those involve four groups, Steinbaum said: people who already have heart disease; those with LDL, the bad form of cholesterol, levels at 190 or higher; and people between 40 and 75 with type 2 diabetes. "And the big one, an estimated 10-year heart disease risk of 7.5 percent or higher," she said.