As adults approach middle age, it’s one of those rites of passage. You go for your annual physical, and your doctor starts talking about scheduling a colonoscopy or mammogram, then double-checks your weight and A1C, and reviews labs to see how your cholesterol numbers are looking. Then you have the talk. Statins, yes or no?
Only now, with new LDL guidelines, is that conversation starting ten years earlier, and the questions are changing. Instead of asking whether to prescribe a statin long-term to slow cholesterol problems, the new guideline asks what the LDL number is now and how to target what it needs to be to prevent a buildup of plaque deposits before they happen.
“The effects of LDL exposure accumulate over a lifetime. Screening at 30 and beginning appropriate interventions earlier can prevent a decade of damage and improve heart health for a lifetime,” said Heath Haggard, MD of Southview Medical Group.
Targeting a specific LDL number rather than making a yes/no decision on whether to prescribe statins allows a more personalized approach for tailoring effective interventions. New guidelines say it is reasonable to begin interventions when labs suggest the risk of heart disease has reached five percent. Patients who also have diabetes, HIV, serious kidney disease and other chronic conditions need to be particularly vigilant in guarding against rising LDL numbers.
“How much help each patient will need varies,” Haggard said. “In families at risk of inherited lipid problems, screening may be warranted in childhood and late adolescence or early adulthood. When the early numbers are high, efforts to control LDLs should start sooner and may need to be more intensive.”
“In average patients whose LDL numbers are borderline or slightly elevated, the decision of whether to prescribe statins and how much is more nuanced. Some may be able to bring their numbers into the target range with healthy eating, activity, stopping smoking and other lifestyle efforts without the need for medication, or with only a minimal dose.”
The LDL number should continue to be monitored as metabolism, aging and the pressures of everyday life change, but it serves as a sentinel to keep patients on course for better heart health through their life.
The pivot to earlier screening may encounter some resistance from patients who consider themselves too young to worry about this. Providers can encourage them with statistics that show that preventing cholesterol deposits can help them keep their biological age younger and avoid consequences like heart disease and stroke that could interfere with them enjoying their full measure of healthy years.
Even among health professionals, there has been some discussion about whether statins are being prescribed too often or at too high a dose, and what the long-term effects on muscles, blood sugar, metabolism and other body systems might be.
Again, having an LDL number as a target can help keep dosages to the minimum needed to achieve benefits. When starting statins, labs should be closely monitored and adjusted as needed.
“If we see a problem developing with one statin, we can try another that might be better tolerated,” Haggard said. “We also have new injectables like Repatha that might be better for some patients depending on their other conditions and medication. There are also non-statin medications that target other pathways, such as Ezetimbie to block absorption and those reducing inflammation to keep blood vessels healthier.”
Another common barrier that can be common is adding the cost of another medication every month.
“Some of the medications that have been around awhile are available as generics that can be quite inexpensive,” Haggard said. “Newer brand names and those offering specialized features may be in the hundreds of dollars. Options may need to be reviewed with pharmacists to develop the best treatment plan for each patient.”
When patients are unable to afford medication or unable to tolerate them due to muscle damage, pain or other side effects, awareness of their LDL numbers can still help them take their heart health into their own hands to minimize long-term problems.
“A moderate Mediterranean diet, avoiding saturated fats, getting regular exercise, stopping smoking, getting enough rest and pursuing a healthy, balanced lifestyle can be helpful for just about everyone.”