Although risk calculators disagree, at some point age becomes the deciding factor in the decision to take a cholesterol-lowering medication.
If you’ve been diligent about monitoring your risk factors for developing heart disease, you may have realized that online calculators can be helpful. If you have the results from your latest cholesterol test, these online calculators can compute your chance of having a heart attack or stroke in the next decade:
Framingham Risk Calculator http://cvdrisk.nhlbi.nih.gov
ACC/AHA Heart Risk Calculator www.cvriskcalculator.com
Reynolds Risk Score www.reynoldsriskscore.org
However, each may give you a slightly different number. And while the Framingham calculator might indicate that your risk is low and therefore you don’t need a cholesterol-lowering statin drug, the ACC/AHA calculator could indicate that you should be taking a statin to reduce your risk.
That really isn’t a problem, according to Dr. Jorge Plutzky, director of the Vascular Disease Prevention Program at Harvard-affiliated Brigham and Women’s Hospital and the medical editor of Managing Your Cholesterol from Harvard Health Publications (www.health.harvard.edu/myc). “Risk calculators provide a ballpark perspective and are best when combined with a fuller assessment,” he says. He adds that the calculators have less of an impact for people who are at extremely low risk and wouldn’t be candidates for medication or for those who are at high risk and would obviously benefit from a statin. “They can be more helpful for that gray area, where people and their doctors are considering going to a statin,” he says.
A majority of women over 50 may fall into that gray zone. Generally, statins are advised for those with a 10-year risk of having a heart attack or stroke that is 7.5% or higher. And because age alone is a powerful risk factor, most women over 65 and nearly all women over 70 will be candidates for statins, even those whose total cholesterol and systolic blood pressures are at optimum levels.
Statins are the most established way to lower cholesterol. They have a proven effect not just on lowering cholesterol (especially LDL, or bad cholesterol) but also in preventing cardiovascular events.
But how low should your cholesterol be? Studies have not tended to pursue a defined target, Dr. Plutzky says. “The most recent version of one set of guidelines (ACC/AHA) have shifted from bringing cholesterol down to a certain point and focused instead on different patient groups and who warrants what ‘intensity’ of statin therapy.” This approach has generated some controversy, with other recent studies suggesting lower LDL is better, with lower cholesterol decreasing the risk of heart attack and stroke. He adds that in most of the trials, the higher the risk, the more of a benefit is seen. For example, older people within the age groups studied got greater risk reduction from a statin because age is a significant risk factor. Similar findings exist for cholesterol lowering among smokers. And for women over 65, the risk of dying from a heart attack or stroke begins to overtake the risk of death from cancer.
Making the statin decision
If you’re undecided, you may want to have your level of high sensitivity C-reactive protein (hs-CRP)—an indicator of inflammation—measured so you can enter it into the Reynolds risk calculator. Some research indicate that hs-CRP may predict risk independent of other known risk factors.
But keep in mind that calculators can only aid, not replace, a discussion with your clinician. Your doctor knows much more about you than the few statistics you plug into the computer apps. You and your doctor can decide if a statin is appropriate for you based on your physical condition, the other medications you take, your lifestyle, and your personal preferences.
While diet and exercise aren’t as effective as statins in lowering cholesterol, they are still important for heart health. A statin won’t free you to become a chip-munching couch potato. Following a healthy eating pattern that may include nuts and seeds, legumes, fish, lean poultry, low-fat dairy, whole grains, vegetables, and fruits is important. So is getting the equivalent of 150 minutes of moderate exercise a week. Both are key to avoiding obesity and staving off diabetes—two important risk factors for heart disease.