In my work as a doctor I see a quite-steady stream of individuals who are concerned about their cholesterol-levels. Usually, these people are male, quite young (often in their 40s) and have been diagnosed with ‘raised cholesterol’. They are also often fit, healthy, non-smoking and free of diabetes and high blood pressure.
Despite the fact that these men have, generally speaking, very low risk of heart disease, they have usually been urged to ‘get their cholesterol under control’. The usual advice is to take exercise (which they’re usually doing) and eat a diet devoid of butter, red meat and eggs. If these approaches do not work, it is often suggested that they should consider taking a statin.
Part of the problem here is that total cholesterol levels or even levels of supposedly ‘unhealthy’ LDL-cholesterol are not accurate guides to the risk of heart disease or other cardiovascular problems. We know, for example, that the size and density of LDL-cholesterol and/or the number of these particles floating around in the bloodstream affects the damage that this may wreak on the vessel walls. Smaller and denser LDL particles and higher numbers of LDL particles (these things go hand-in-hand) are linked with heart disease but larger, less buoyant and less plentiful LDL particles are not. However, this detail is completely missed by standard blood tests.
However, there is some sense that the tide is beginning to turn regarding what is regarded as good practice with regard to cholesterol management. About a year ago, I wrote this post which highlighted the views of US Professor of Medicine and cardiologist Harlan Krumholz, who pours cold water on conventional cholesterol management. Part of his argument is that treating to get LDL cholesterol levels down to a particular level has never been tested. It’s an example of a common medical practice that is not actually ‘evidence-based’, though my experience is that there are plenty of doctors around who believe it is.
More recently, Dr Krumholz featured in a report in the journal Nature which, again, highlighted some of the problems with conventional cholesterol management. I reported on this here.
A study was published recently which, I think, highlights a need for some shift in doctors’ thinking and practice with regard to cholesterol management . In it, 750 doctors in the US were surveyed, with each being presented with a vignette of 6 hypothetical people. Doctors were asked which of these people they would likely treat with statins over the coming years.
One of these vignettes was a 40-year-old man, with ‘raised’ LDL levels and normal blood pressure (just the sort of person I see quite-often in practice). The authors of the research point out that this man is actually at low risk of cardiovascular disease and very unlikely to benefit from statin therapy. Nonetheless, the great majority of doctors said they would treat this man with statins.
The authors of the study suggest, sometimes, we doctors don’t do a particularly good job of assessing overall risk when making treatment decisions and recommendations. A major problem, here, is that we doctors can be stuck on the ‘all-important’ LDL-cholesterol levels.
As I’ve said before, I think we doctors have been subjected to a form of collective brainwashing on cholesterol and its role in heart disease. The fact remains that we will often prescribe statins to people who have very little chance of benefiting from them. These drugs are not without risk either – a critical point that I did not evade the authors of this recent survey.
The bottom line is that we doctors can often end up recommending statins for people for whom they are more likely to do harm than good.
1. Johansen ME, et al. A National Survey of the Treatment of Hyperlipidemia in Primary Prevention. JAMA Intern Med. Published online 11 March 11 2013