Statin-type cholesterol-lowering drugs are among the most popular medications in the pharmacy. At last count, nearly 30 million Americans are taking atorvastatin alone. Another 20 million are taking other statins such as simvastatin, rosuvastatin or pravastatin. According to the American Heart Association “Nearly half of U.S. adults – more than 122 milion – have high blood pressure.” Doctors have been encouraged to be aggressive in treating both high blood pressure (BP) and elevated cholesterol. But a new risk calculator and cholesterol guidelines might relax those recommendations. Will that lead to unnecessary deaths?
The Roller Coaster of Cholesterol Guidelines:
American physicians have been strongly encouraged to use a risk calculator created by the American Heart Association (AHA) and the American College of Cardiology (ACC). This ASCVD (Atherosclerotic Cardiovascular Disease) Risk Estimator used to be quite aggressive in its recommendations about statin therapy and blood pressure treatment.
You can read the details about the old statin suggestions at this link:
“Should Everyone Over 65 Take a Statin to Prevent a Heart Attack?”
In the “old” days, doctors would use the risk calculator to determine what a patient’s 10-year risk of cardiovascular disease (CVD) might be. People at “intermediate” risk of CVD were defined as having a 7.5%-20%, 10 year risk of CVD. Depending upon cholesterol levels and other factors a doctor might prescribe “high-intensity” statin therapy (40-80 mg of atorvastatin daily) or “moderate-intensity” statin therapy (10-20 mg of atorvastatin daily).
We have pointed out some of the flaws in the old risk calculator. For example, even men in excellent health could be put on a statin just because of age. We described the example of a vegetarian over 64 who ran 5 miles a day, had a blood pressure of 120/80 and total cholesterol of 170. This person had “good” HDL cholesterol of 65 and no history of blood sugar elevation. The risk calculator still encouraged statins.
There is a New Cardiovascular Risk Calculator Called PREVENT!
A new risk calculator proposed by the American Heart Association would reduce the number of people who would be encouraged to take a statin. The calculator is labeled PREVENT. It stands for Predicting Risk of Cardiovascular Disease Events. If cardiologists adopt the PREVENT recommendations, 14.3 million people would no longer need to take statins. Additionally, 2.62 million Americans would no longer need antihypertensive therapy.
That is a sea change from prior blood pressure and cholesterol guidelines. But an analysis in JAMA (July 29, 2024) pushes back.
The authors suggest that adopting the PREVENT calculator could lead to more than 100,000 heart attacks over 10 years. Almost 5 million Americans would be prescribed moderate-intensity rather than high-intensity statins. Over 2 million people would no longer need blood pressure medications under the PREVENT guidelines.
The authors conclude:
“With no change to current risk-based treatment thresholds, widespread adoption of the PREVENT equations for ASCVD risk could reduce eligibility for statin and antihypertensive therapies among an estimated 15.8 million US adults and thereby increase the rate of major adverse cardiovascular events. Although PREVENT advances the important goal of more accurate and precise cardiovascular risk prediction, the magnitude of these projected changes warrants careful reconsideration of current treatment thresholds using decision-analytic or cost-effectiveness frameworks.”
Cardiologists Are Conflicted About the Cholesterol Guidelines:
In case this all seems academic, let me try to explain succinctly what the fight is about. The PREVENT approach wants to relax the older, more aggressive approach to cholesterol and blood pressure treatment.
The cardiologists who favor PREVENT believe that the older risk calculator overestimated the risk of cardiovascular disease. Under the new guidelines, millions of people would no longer be admonished to take a statin or BP medicine.
But old habits die hard. Many cardiologists believe the older cholesterol guidelines were better. They insist that “bad” LDL cholesterol needs to be as low as possible and that relaxing the guidelines will lead to unnecessary deaths.
An editorial in JAMA (July 29, 2024) is titled:
“The Evolving Landscape of Cardiovascular Risk Assessment”
It tries to put the argument into perspective. The authors suggest that we still need optimal risk thresholds to figure out future guidelines for both blood pressure and cholesterol treatment. They encourage their colleagues to motivate patients to establish “sustained lifestyle changes” and prescribe statins and BP meds only to those people who are most likely to benefit.
If there is a take home message it is that risk calculators, blood pressure and cholesterol guidelines are constantly changing. What seems written in stone today may be quite different a decade from now as new data are collected.
Please share your thoughts about blood pressure treatment and cholesterol control in the comment section below.
