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Unravelling the facts about 'high cholesterol'

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There was a rare ray of hope illuminating the cholesterol world this week when it was revealed that most people who are taking cholesterol-lowering (statin) drugs probably should reconsider that decision. Statins include drugs such as Crestor, Lipitor or Zocor, and are currently consumed by nearly 20 per cent of the Canadian adult population.

New guidelines issued by a few major heart organizations in the U.S. now say people don't really need to be aiming for certain numerical targets by swallowing statin drugs. Perhaps the guideline writers realized this obsession with "lower is better" around cholesterol levels isn't based on any solid evidence. Despite the fact some researchers and physicians have been saying the same thing for years (and I've been ranting about this for at least a decade), the Good Ship Cholesterol is finally starting to alter its course.

People religiously swallowing their daily statin need reminding that cholesterol is a valuable substance in our blood and levels of so-called high cholesterol have always been an artifact of the pharmaceutical industry and those clinicians who believe in the "lipid theory." Even with known harms of statins (muscle-weakening, cognitive problems), the drug industry, along with cholesterol "experts" have created a massive market worth billions of dollars by getting people (including our doctors) to worry about cholesterol targets and driving patients to swallow drugs to achieve those targets.

This new announcement is controversial, with some cardiologists calling it a major course alteration in how doctors will treat people considered at high risk of cardiovascular disease. Others say the changes lower the thresholds at which people are considered high-risk, and this will lead to even more statin overtreatment.

I can't predict the effects of the new guidelines, but one thing that is very hopeful about them is they emphasize "patient preferences." When people realize that a daily statin for five years reduces the chance of a cardiovascular event by about one per cent (or five to seven per cent if you have already had a heart attack), they might come to the conclusion that statins aren't worth the hassle, risk of adverse effects and the financial costs.

Knowing the minuscule effects of high cholesterol, I think, will lead people to seek out other -- perhaps healthier and safer -- ways to lower their cardiovascular disease risk.

The new guidelines, put out by the American Heart Association and the American College of Cardiology, are saying that targeting numerical values of what is considered ideal cholesterol is the wrong approach. As with any treat-to-target approach, a number of people will never reach the targets, no matter how strong a statin they swallow, and then they are left with anxiety and feeling like a ticking time bomb just because of an arbitrary threshold that they couldn't get below.

There are a lot of things that determine your risk of future cardiovascular disease, and any online Framingham calculator will help you put some numbers around what your personal risks might be. But just because something is a risk factor doesn't mean lowering it will reduce or eliminate that risk.

These new guidelines also put the kibosh on so-called cholesterol-boosting drugs such as ezetimibe (trade names: Ezetrol or Zetia), which most independent analysts have been calling a massive waste of money ever since they hit the market. This drug might lower your LDL cholesterol, but so what? Does it make a difference in your chances of having a heart attack or stroke? There's no evidence to support that. Despite this lack of any meaningful effect, it still makes its manufacturer, Merck, nearly $3 billion per year.

It's debatable whether these new guidelines will increase or decrease the use of cholesterol-lowering drugs. At the very least, I think they may well help people relax, and that's a good thing. When patients start to ask their doctors about the benefits, the potential adverse effects of the drugs and the risk of drug-to-drug interaction, a fuller and more comprehensive discussion can happen about what swallowing a daily statin will ultimately mean for them.

At the end of the day, people can talk to their doctor about what they can do to reduce a future risk of heart attack or stroke, and that advice hasn't changed: a healthy diet, adequate exercise, not smoking -- the usual triumvirate of healthy living advice. To that, I'll add one more: Don't worry, be happy (and stop obsessing about your cholesterol numbers).

Alan Cassels is an expert adviser with EvidenceNetwork.ca, and a pharmaceutical policy researcher in Victoria.

Republished from the Winnipeg Free Press print edition November 25, 2013 A9

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