The fundamental shift: Doctors are now being told to no longer adhere to rigid clinical guidelines that trigger the use of a statins when cholesterol levels reach a certain threshold.
Instead, people will be advised to take a statin if they already have heart disease, if their bad (LDL) cholesterol is extremely high (190 milligrams per decilitre of blood or more) or if they're middle-aged with type 2 diabetes.
People between 40 and 75 years of age with an estimated 10-year risk of heart disease of 7.5% or more will also be advised to take a statin. Experts say this new rule could greatly alter the number of patients who will now be advised to take such a drug.
In crafting the new guidelines, experts from the American Heart Association and American College of Cardiology spent four years examining the data on heart disease care.
Appropriate level of statin therapy
The new criteria for who should take a statin also now factors in a person's risk for stroke, something experts believe may also boost the number of people deemed eligible for the drugs.
"We focused specifically on the use of cholesterol-lowering therapy to determine what works best to reduce the risk of heart attack and stroke," Dr Neil Stone, a professor of medicine at the North-western University Feinberg School of Medicine and chairman of the cholesterol committee, said during a press conference.
The revised cholesterol policy "suggests treatment should be individualised and that, depending on your risk, you may need a higher dose of a more potent statin than if your risk is lower," Dr Hector Medina, a cardiologist at Scott & White Healthcare in Round Rock, Texas, told HealthDay.
Statins, which include Crestor, Lipitor and Zocor, remain the most effective drugs for reducing cholesterol and should be combined with lifestyle changes for the best results, according to the new report. This approach is better than trying to get cholesterol as low as possible by combining statins with other drugs, the report's authors said.
The committee also said matching patients with the appropriate level of statin therapy is more important than achieving any specific target number, as was common in the past.
For young adults, preventing high cholesterol in the first place can go a long way toward avoiding heart attacks and strokes, the committee added.
About one-third of adults at risk for a heart attack or stroke have not been diagnosed but could benefit from primary prevention – including taking statins – according to the report.
Doctors should use known risk factors – such as age, cholesterol levels, blood pressure, smoking and diabetes – to assess cardiovascular risk. "These are the strongest predictors of 10-year risk for cardiovascular disease," Dr Donald Lloyd-Jones, a professor of preventive medicine at the North-western University Feinberg School of Medicine and co-chairman of the committee, said during the press conference.
Patients at risk of a heart attack or stroke within the next 10 years should get immediate drug therapy and be encouraged to change their lifestyle, Lloyd-Jones said.
On the other hand, those at lower risk of heart attack or stroke should be counselled to make lifestyle changes and probably do not need drug therapy, he said.
Reducing obesity also cuts heart-health risks, and the new guidelines may help doctors and their plus-sized patients devise an effective and perhaps lifesaving weight-loss plan.
What works best are lifestyle changes, not crash diets, the authors of the new guidelines said.
"Our recommendation is that doctors prescribe a diet to achieve reduced caloric intake as part of a comprehensive lifestyle intervention," guideline co-author Dr. Donna Ryan, a professor emeritus at Louisiana State University's Pennington Biomedical Research Centre in Baton Rouge, said during the press conference. The diet should be tailored to patient preferences and any drugs they take, she said.
Diet, physical activity and face-to-face behavioural counselling combined can lead to "clinically meaningful health improvement," Ryan said. "These benefits begin with weight loss in the range of 3% to 5%." The most effective behaviour programmes include two to three meetings a month for six months or more, according to the report.
Medication to manage heart health
Nearly 155 million American adults are overweight or obese, which puts them at risk of heart attack, stroke, diabetes and early death. Weight loss will lower blood pressure, improve blood cholesterol levels and reduce the need for medication to manage heart health, Ryan said.
For Americans, heart disease is the leading cause of death.
The experts said doctors should use a patient's body-mass index (BMI) to assess whether a patient is obese or not. BMI is a measure of body fat based on height and weight; a BMI of 25 or more is overweight.
"BMI is a quick and easy first screening step," Ryan said. Calculating BMI at least once a year will help identify those at a higher risk of heart disease and stroke because of their weight, she added. Waist circumference is also an indicator of risk.
Weight-loss surgery, also called bariatric surgery, may be the right option for those who are severely obese (a BMI of 35 or higher), especially if they have two other cardiovascular risk factors, such as diabetes and high blood pressure.
This emphasis on obesity is critical, said Medina, who was not involved with the report.
The problem? "Most patients don't think they are overweight or obese even with a BMI above 40," he said.
Besides reducing obesity, the new guidelines emphasize the need to maintain safe cholesterol levels, eat a healthful diet and assess other risk factors for heart attack and stroke.
Healthy Diet and Exercise
A healthy diet not necessarily a low-calorie diet and exercise reduce the risk for cardiovascular disease by lowering blood pressure and cholesterol.
"Dietary patterns that are heart-healthy... include lots of fish, vegetables and whole grains, and limit saturated fats, trans fats and sodium," cholesterol committee co-chairman Dr Robert Eckel, a professor of medicine at the University of Colorado Anschutz Medical Campus in Aurora, said during the press briefing.
A heart-healthy diet of 2 000 calories per day should include:Four or five servings of fruit daily, four or five servings of vegetables daily, six to eight servings of whole grains daily, two or three servings of fat-free or low-fat dairy products daily, six or fewer ounces of poultry or fish daily, four or five servings of nuts, legumes and seeds a week, two or three servings of healthy oils a day, limited sweets and sugars.
To reduce high blood pressure, limit salt intake to 1 500 milligrams a day, the committee said. US adults currently consume an average of about 3 600 milligrams a day.
One key to heart-healthy eating is avoiding trans fats, which serve no nutritional purpose but are often added to foods to extend shelf life or improve texture. The US Food and Drug Administration announced a plan last week to ban these man-made fats from all processed foods. These are often listed on labels as partially hydrogenated oils.
The guidelines also recommend moderate- to vigorous-intensity aerobic exercise, such as brisk walking, for about 40 minutes three or four times a week.
For more information on preventing heart attack and stroke, visit the American Heart Association.