Recently released guidelines could change the way women are treated with statin drugs.
High cholesterol is a concern to women as we age. Before menopause, estrogen protects us from heart disease, in part by increasing our HDL (good) cholesterol and lowering LDL (bad) cholesterol. But by our 50s, more than half of us are dealing with elevated cholesterol levels, and with them, an increased risk for heart disease.
In the past, we lowered our cholesterol by the numbers, aiming for specific targets to reduce our chances of developing heart disease. Now that approach is changing. In November 2013, the American College of Cardiology (ACC) and the American Heart Association (AHA) released new guidelines to help prevent heart attacks, strokes, and other consequences of heart disease. The guidelines focus on heart disease risks rather than cholesterol numbers, and they could increase the number of women for whom statin drugs are recommended.
There has been some controversy over potentially putting more people on statins, but the new recommendations are meant to serve as a guide to heart disease prevention—not a mandate. “As with any guideline, decisions regarding therapy should be patient-centered. Women are encouraged to discuss the potential impact of the new guidelines on their care with their health care provider,” says Dr. Joanne Foody, co-director of preventive cardiology at Harvard-affiliated Brigham and Women’s Hospital.
Out with the old
Under the previous guidelines, the goal was to lower LDL cholesterol levels to defined targets:
below 160 mg/dL if you were at low risk for heart disease
below 130 mg/dL if you were at moderate risk for heart disease (a 10-year risk of between 10% and 20%)
below 100 mg/dL, or as low as 70 mg/dL, if you were at high risk (a 10-year risk of greater than 20%).
Your doctor would have considered putting you on a statin drug if your LDL cholesterol was in the moderate risk range or above.
In with the new
When an expert panel reviewed the research on the use of statins to reduce heart disease risk, they found that statins have benefits in people at risk for heart disease, even if they have normal cholesterol levels. So they instead recommended a new strategy that focuses on risk rather than cholesterol numbers.
Under the new guidelines, the goal is to lower blood cholesterol in the four groups of people who are most likely to benefit from statins. Your doctor will very likely recommend that you start taking one of these drugs (if you aren’t taking one already) in any of these circumstances:
You have coronary artery disease.
Your LDL cholesterol is 190 mg/dL or above.
You have type 2 diabetes.
Your 10-year heart disease risk is 7.5% or higher based on an AHA/ACC risk assessment tool.
Treatment based on your risk
If your doctor does suggest statins, you might be nervous about starting on these drugs because of their potential side effects, which include muscle pain and an increased risk for diabetes. Yet Dr. Foody says the balance tips in favor of trying these drugs if you qualify for them. “In general, if women are deemed appropriate candidates based on these guidelines, the potential benefits in terms of heart disease risk reduction outweigh side effects,” she says.
How will the new guidelines affect women who are already taking a statin? “It is likely that the majority of women on a statin will remain on a statin,” Dr. Foody says. Yet your doctor will probably re-evaluate your dose. Instead of trying to achieve a set LDL goal, you’ll receive a certain intensity of statin therapy based on your risks:
High-intensity statin therapy lowers LDL by 50% or more. You’ll likely get this therapy if you have heart disease or are at high risk for heart disease, or you’re over age 75.
Moderate-intensity statin therapy lowers LDL by 30% to 50%. You may get moderate-intensity therapy if you’re not a candidate for high-intensity statins, but your heart disease risks are still relatively high.
And what if you currently take another class of drug, such as niacin or bile acid resins, to lower cholesterol? “In general, there is very little, if any, evidence supporting the use of drugs other than statins for reducing cardiovascular risk,” Dr. Foody says. “Given that, women who are on these drugs should discuss with their doctor whether a statin might be more appropriate.”
Remember that these new recommendations aren’t the final word on your therapy. Base your treatment on your health history, your doctor’s recommendations, and your own preferences.
Regardless of whether you’re put on a statin drug, don’t neglect lifestyle interventions, which Dr. Foody calls the “cornerstone of heart disease risk reduction.” Eat a diet rich in vegetables, fruits, whole grains, low-fat dairy, poultry, and fish. Limit sweets and red meats, as well as other foods high in saturated fat and trans fats. And get moderate aerobic activity on most days each week.