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Folderol Over Cholesterol

November 21, 2013

I promise I will say nothing about Obamacare.  I will say nothing about insurance, cancellation thereof, or anything about the Republicans God bless their sorry souls.  I do have to speak out just a little about the new cholesterol guidelines that have made some headlines in the last few days.  All I can say is: thank God for Harlan Krumholz.  Voice of reason and measured statement.  He doesn’t know this, but I used to work with him back when I was a cardiac nurse at Yale-New Haven Hospital.  I have it on good authority that his residents remember him too!  He is an excellent and well-known cardiologist and not a bad writer either.  The kerfuffle about the new cholesterol guidelines was very reasonably explained by Dr. Krumholz in the NYT on November 12 as the following:

1. The guidelines have moved away from achieving target cholesterol levels.   (That is, it’s not a competition…)

2. Know your risk.  (The online calculator…)

3. Use medications proven to reduce risk.  (Drugs…)

OK, so let’s start with number one.  Here is what Dr. Krumholz says:

“The new guidelines recognize that FOR PATIENTS WHO HAVE EXHAUSTED LIFESTYLE EFFORTS (capitals my addition) and are considering drug therapy, the question is not whether the drug makes your lab tests better, but whether it lowers your risk of heart disease.”

Oh man!  Don’t take away our target numbers! Weight, amount needed to retire, how many cars we own, how many levels we can dial up on ours spin bikes, who has the most toys, we need the numbers!  No, we don’t.  We want to be healthy as long as possible and enjoy our later years.  None other than the American Heart Association is telling you to relax.  Exercise, don’t smoke, take your statin if you must, but relax.  Stress increases your risk of heart attack.

The second point – here is where the problem lies.  I was all excited about this online calculator (another number woo hoo!).  I jumped on to compare my far superior low number to my husbands and gloat.  I’m female, white, I (used to) exercise, not overweight, don’t smoke, under 50, not diabetic.  Maybe it’s not working.  Maybe I don’t understand.  Maybe my browser is out of date.  I don’t know.  I got an 8% risk.  Really?  OMG I need a statin stat! It turns out the calculator may be flawed, as Dr. Paul Ridker and Dr. Nancy Cook have pointed out to the guideline makers, and apparently in a commentary in The Lancet that you have to pay $31.50 for the privilege of reading.  Dr. Krumholz again comes to our rescue:

“However, I believe that only you (his italics) can determine what constitutes a high enough risk that it is worth it to you to be treated with drugs.  Such a decision depends on how you feel about your risk of heart disease and stroke and how you feel about taking drugs – and their risks and benefits.”

Relax.  Seriously.  Exercise, don’t smoke, take your statin if you must, don’t stress.  And stay away from that calculator.

The third point – drugs.  There are a lot of cholesterol-lowering drugs out there.  Big business.  These drugs might lower your lab number (your number!).  Other than statins (Lipitor etc.) they have not been shown to actually do what you really want, which is to lower risk.  But I need a number!  No, you don’t.  Relax.  Exercise, don’t smoke, take your statin if you must, don’t stress.  The American Heart Association, the American College of Cardiology, and my old friend Dr. Harlan Krumholz are telling you.

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