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Cardiologists recommend wider use of statin drugs

Revised guidelines, which could double the number of Americans taking the cholesterol-lowering medications, emphasize statins' ability to prevent heart attacks and strokes.

November 12, 2013|By Melissa Healy
  • A generic form of the statin Lipitor. New recommendations say about 70 million Americans should be taking such drugs, nearly double the current number.
A generic form of the statin Lipitor. New recommendations say about 70 million… (Bill Gallery / Watson Phramaceuticals )

Dramatically escalating the fight against heart attacks and strokes, the nation's cardiologists have rewritten the guidebook on how Americans should be treated with statins and unveiled a plan that could double the number of patients taking the cholesterol-lowering drugs to about 70 million.

The new approach, presented Tuesday by the American College of Cardiology and the American Heart Assn., represents a stark shift from the way doctors have prescribed the popular drugs for most of the last decade.

Physicians who have focused on reducing the LDL cholesterol of patients who are at greatest risk of a heart attack will now be urged to refocus their efforts on using statin therapy on a wider range of at-risk patients, many of them still relatively healthy, to drive down their odds of a heart attack or stroke.

The new guidelines distinguish between patients who should get high-dose statin therapy and those who can take a lower dose less likely to cause side effects, such as muscle fatigue. They also instruct physicians to discontinue their efforts to meet strict targets for LDL, the "bad" cholesterol that's most closely linked to disease risk.

Cholesterol is essential for digestion, hormonal balance and cell function, but too much of it can gum up arteries. Crestor, Lipitor, Zocor and other statins reduce cholesterol by blocking the liver's production of the waxy substance.

Americans filled 255 million prescriptions for these and other cholesterol-lowering drugs in 2012, according to IMS Health, a research firm that tracks prescription drug trends. Yearly spending on this class of drugs peaked at $21.3 billion in 2011, declining since then as more of those brand-name medications become available as generics.

In proclaiming statins the most effective tool for preventing heart attacks and strokes, the writers of the new guidelines downplayed concerns about the medications' side effects. These include muscle aches and fatigue, a slight rise in blood sugar and, more rarely, hemorrhagic stroke and a toxic breakdown of muscle tissue called rhabdomyolysis.

Some experts worried that such side effects would become much more common as the population of statin-takers swells in response to the new guidelines. That could lead many patients to abandon the treatment and cause problems for others who stick with it.

"They underrate the risk" of important side effects such as muscle weakness and the kind of stroke that involves bleeding into the brain, said Dr. Sanjay Kaul, a Cedars-Sinai Medical Center cardiologist and UCLA professor of medicine. For patients with a comparatively low risk of heart attack or stroke — patients who essentially are still healthy — it'll be a harder sell, he said.

Under the new protocols, physicians should make an urgent case for taking statins to all patients whose high risk of having a heart attack or stroke because of plaque buildup is indisputable: those who have already suffered a heart attack or stroke, adults between the ages of 40 and 75 with Type 2 diabetes and people with exceptionally high LDL levels due to faulty genes.

The guidelines also recommend that patients with lower odds — those judged to have at least a 7.5% chance of suffering a stroke or heart attack over the next decade — be prescribed a low-dose statin to reduce their risk. The panel of cardiologists writing the guidelines devised a "risk calculator" that considers a patient's age, gender, cholesterol levels, blood pressure, smoking history and other variables to come up with an individualized probability estimate.

Until now, treatment with cholesterol-lowering drugs in the U.S. has generally been limited to patients with a 20% probability of a heart attack over the next decade — about 36 million Americans. The expanded treatment guidelines would roughly double that figure, the authors said.

That increase would be driven in part by the inclusion of people at risk of suffering ischemic stroke, a reduction in blood flow to the brain caused by arteries narrowed by plaque buildup or a breakaway blood clot.

Statins have been shown to reduce the risk of stroke as well as heart attack. But by explicitly counting stroke-prevention among statins' benefits for the first time, the authors of the new guidelines hope to extend statin therapy to more of the patients who are most susceptible to stroke, including women, African Americans and the very elderly.

Dr. Neil Stone, chief author of the new clinical practice guidelines, said Americans' health would benefit from a more vigorous approach to identifying and treating patients who are vulnerable to heart attacks and strokes, not just those with too much LDL.

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