Continuing the Conversation on Cholesterol Management
In a recent blog post on lipid management, I mentioned that the cholesterol numbers and risk score should be the start – rather than the end – of a conversation. While we’ve begun to take a more personalized approach over the last decade, the current risk calculators and decision tools aren’t perfect. So what else do doctors consider when thinking about your risk?
For some patients, there are clear cut indications for statin drugs – those with prior heart disease, diabetes, or very high cholesterol LDL numbers. But what about the otherwise healthy patient who find themselves in the “statin zone?” How do we better inform the decision of starting a medication for the long term?
“Risk Enhancers” for ASCVD
Well, we should be taking into account “risk enhancers” – or other risk factors that increase one’s risk of ASCVD (atherosclerotic cardiovascular disease – defined as non-fatal heart attack, death from cardiovascular disease, or stroke) beyond what is estimated in the risk calculator. One significant risk enhancer that we commonly think of is having a first-degree family member with “premature” ASCVD. Premature in this context means onset of less than age 55 for males, and for females onset younger than age 65. Other risk enhancers don’t seem to be as well known and include chronic kidney disease, chronic inflammatory conditions like rheumatoid arthritis, HIV, or psoriasis, south Asian ethnicity, presence of the metabolic syndrome. For women, we should also consider whether you have a history of premature menopause and even pre-eclampsia during a prior pregnancy – both of which are risk enhancers. Finally, having a persistently elevated LDL or triglycerides can be a risk enhancing factor, even though these aren’t part of the calculator we use. If a patient has any of these risk enhancers – or more than one – this may sway us toward starting a statin.
Photo by National Cancer Institute
Will I Really Benefit From a Statin?
Other people may want to know if they’ll really benefit from taking a statin, especially if they don’t have any risk enhancers and would prefer to avoid a daily medication. These patients may be candidates for a CT scan to assess their coronary artery calcium (CAC) score. A score of zero in an otherwise low risk patient indicates a very low risk of ASCVD in the next few years – and might sway us away from statin medications and towards continued healthy lifestyle as the main strategy to prevent ASCVD.
The changes to the guidelines on lipid management over the last ten years have improved our ability to personalize treatment for our patients. Having in-depth conversations about ASCVD risk is much more challenging for me than looking at a number and deciding whether or not to pull out the prescription pad – but I like to think it’s much more rewarding for both patients and physicians.