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The Simple Truth About Cholesterol

The New York Times recently ran a piece that wondered if doctors were treating patients with cholesterol-lowering medication unnecessarily because a web-based calculator over estimated a person’s risk. The program was proudly sponsored by the pharmaceutical roundtable and was available at the American Heart Association.

The implication was obvious. Simple tool determines an individual’s risk for heart attack or death from heart attack. It over estimates risk. Patients treated unnecessarily. To be also clear, the program did underestimate risk as well.

Unfortunately, the article missed an important point. While the simplified calculator may not be as accurate as the more complex algorithm used by the National Cholesterol Education Program, the truth is doctors are likely to be overtreating patients not because the former program is presented by the pharmaceutical roundtable, but for another reason.

In my experience, doctors don’t use any web-based tool. Instead they use a simple rule — is the cholesterol over 200, which is even less precise than the vilified web calculator. This is rather disappointing, yet occurs too often.

The public has been told erroneously that if your cholesterol is over 200 that it is bad. Understandably to generate public awareness, a simple number is far easier to act on than the messier nuances determined by the Framingham heart study. This classic and famous study found that total cholesterol and HDL (good) cholesterol, the age, gender, smoking status, blood pressure, and whether a person is taking blood pressure medication could provide an estimate of an individuals chance of having a heart attack or dying of one over the next 10 years. In other words, it isn’t just the cholesterol in isolation that predicts heart disease, but the profile of the whole person that does.

As a result of these calculations, some basic guidelines appeared.  Patient with a risk of greater than 20% over the next 10 years should be on cholesterol lowering medications like the “statins.” Those with a risk of 10% or less should simply work on dietary changes, maintaining a healthy weight, and exercise. Those between 10 and 20% should also adopt lifestyle changes and consider cholesterol lowering medication.

The decision tree is now far more sophisticated than simply treating a total cholesterol of over 200 with medication.

So when patients join my practice, particularly those who do not have high blood pressure, diabetes, or a history of heart disease, and who are on medication to lower cholesterol, I do this calculation with them. Shockingly, many don’t need medication. The only exception is patients with diabetes or heart disease where cholesterol lowering medication is a must. 

Though these patients are pleased, they are also somewhat reluctant. Everyone else they know is on cholesterol lowering medication. Bucking peer pressure, even when scientifically grounded, can be incredibly difficult. It goes to show how powerful and effective the public service announcements have been to generate awareness. It also shows how difficult it is to fight a perception, even when it is wrong, particularly when other doctors for expedience sake give patients what they think they want rather than what they need. (Ever gotten antibiotics for a cold or viral illness instead of reassurance and TLC?)

So if your doctor tells you that you need cholesterol lowering medication, ask him how he reached that conclusion. He might be doing a simple mental shortcut rather than taking a few minutes to determine your risk. Ask him if he can quantify your risk over the next 10 years. If you hasn’t an idea what you are talking about,then ask him to Google “10 year risk calculator” to find the right test.

If you don’t have diabetes or a history of heart disease and you do discover with a calculation that cholesterol lowering medication is prudent, the good news is there are a few excellent generic medications available to do the job.

Just don’t ask for Lipitor the most widely prescribed cholesterol lowering medication. It’s very powerful yet most people don’t need that level of potency to protect themselves from heart attack.  It’s expensive as it isn’t generic yet. You probably will do just fine with the generic version of Zocor, simvastatin. Don’t take my word for it; that is the conclusion by medical experts for Consumer Reports. If you are already on cholesterol lowering medication, don’t stop until you check with your doctor to make sure it is safe to do so.

Remember: It isn’t what you think you want, it’s what you need. Marketing of Lipitor or public service announcements about cholesterol can shape what you think you want. Talking candidly with your doctor may actually help you determine what you need. Not only might this save you money, but also prevent you from being unnecessarily overtreated.

*This blog post was originally published at Saving Money and Surviving the Healthcare Crisis*

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