In August, the U.S. Preventive Services Task Force released its latest guidelines on the use of statins – the most commonly prescribed class of cholesterol-lowering drugs – for preventing a first heart attack or stroke. The updates are based on a review of new evidence assessing the benefits and harms of statins since publication of its previous recommendations in 2016. And the new guidelines are more conservative than those developed by the American College of Cardiology and the American Heart Association.
Did you know?
The USPSTF guidelines now recommend statins for adults ages 40 to 75 who have one or more risk factors of cardiovascular disease and a 10% or greater risk of having a heart attack or stroke in the next 10 years. Risk factors include diabetes, high blood pressure, smoking and high cholesterol. Scores are calculated using a person’s age, sex, race, blood pressure, cholesterol numbers and family history.
Current guidelines conclude that evidence is insufficient to determine benefits and harms of statin use for the primary prevention of cardiovascular events and mortality in adults 76 or older with no history of the disease.
For people who have a slightly lower (7.5% to 10%) risk of having a heart attack in the next 10 years, guidelines recommend consulting with a physician on whether statins are the best course of treatment to lower risks for having a stroke or first heart attack. For this group, lifestyle interventions such as diet and exercise are recommended first to reduce overall risks.
Since the USPSTF previously revised its statin guidelines in 2016, several new studies have been published on the effectiveness of the drug. To make these new recommendations, the group reviewed 26 studies involving more than half a million patients that compared results from people who took statins and those who didn’t. Researchers reported statins were significantly associated with decreased risk of all-cause mortality across all demographics.
In the past, there had been some concern that statins may elevate a person’s risk for muscle problems or diabetes, but the latest studies used to create the new guidelines did not show a real increase in either problem.
Differences in new guidelines
Commenting on the report, Dr. Edward Fry, MD, president of the ACC, said the USPSTF guidelines are statements to be applied to a broad group or population of patients, but the ACC and AHA guidelines are directed more toward the individual. Neither makes statins an automatic decision for a patient. Any medical decision instead needs to be made on an individual basis, and the guidelines provide a road map, said Fry. Experts conclude overall differences between the old and new guidelines are insignificant.
One area not covered in the new USPSTF guidelines is a person’s coronary calcium score. A heart scan can detect calcium in the coronary arteries, as there’s an established relationship between calcium and plaque. The score can be used for a patient who is borderline between a high or intermediate risk as a determining factor in recommending statins.
The evolution of statins
For nearly four decades, statins have been the most widely prescribed therapy for secondary and primary prevention of cardiovascular disease and death. Without question, widespread use of statin therapy has been a major public health advance, especially when used in high doses for patients at highest risk.
Yet, experts report that statins are still used suboptimally (i.e., not high-intensity doses) in the highest-risk individuals, and that women, racial and ethnic minorities, and the uninsured are all treated far less than might be expected based on risk guidelines.
To further the research on statin use, especially for those over 75 with no previous history of cardiovascular disease, the National Institute on Aging is currently running a large clinical randomized trial – Pragmatic Evaluation of Events and Benefits of Lipid-Lowering in Older Adults – which is expected to be completed in 2026.
Asking your doctor if statins are right for you
If you think you or your loved one may be a candidate for statin therapy, discuss the following with your physician:
- Do I have other risk factors for heart disease?
- Am I willing and able to make lifestyle changes to improve my health?
- Am I concerned about taking a pill every day, perhaps for the rest of my life?
- Am I concerned about statins’ side effects or interactions with other drugs?
Whether your older adult needs to be on a statin depends on their cholesterol levels and other risk factors for cardiovascular disease. Their doctor will consider all risk factors for heart attacks and strokes before prescribing a statin.
Make sure they know their cholesterol numbers. Most people should try to keep total cholesterol below 200 milligrams per deciliter (mg/dL), or 5.2 millimoles per liter (mmol/L). Aim to keep LDL (the “bad” cholesterol) under 100 mg/dL, or 2.6 mmol/L.
If your loved one has a history of heart attacks or is at a very high risk of a heart attack or stroke, they may need to aim even lower (below 70 mg/dL, or 1.8 mmol/L). The most important thing their doctor will keep in mind when talking to them about statin treatment is their long-term risk of a heart attack or stroke. If the risk is very low, they probably won’t need a statin, unless LDL is above 190 mg/dL (4.92 mmol/L).
Their doctor may use an online tool or calculator to better understand their long-term risks of developing heart disease. These tools can help predict chances of having a heart attack in the next 10 to 30 years. The formulas in the tools consider cholesterol levels, age, race, sex, smoking habits and health conditions.
Need a second opinion?
Going on a statin can mean taking the drug indefinitely, so caregivers and older adults are always encouraged to consult other physicians to learn about other options.
The second doctor can review your loved one’s medical history and give their interpretation of their health, as well as provide a diagnosis or treatment plan (and possibly a different treatment).
Getting a second opinion may helpful when:
- Health insurance requires a second opinion.
- The diagnosis isn’t clear.
- Your senior has a lot of medical conditions.
- The treatment offered is experimental, controversial or risky.
- An older adult has a rare or life-threatening condition.
- Many treatment options are available.
- Your loved one isn’t responding to treatment.
- Your loved one feels like they can’t talk to their current doctor.
- Their doctor says they can’t help them or won’t treat them.
- The doctor doesn’t specialize in your loved one’s condition.
- You want peace of mind.
The best place to start the process is with your loved one’s primary care doctor. If they haven’t offered a referral to a specialist, ask for one. If your senior is already seeing a specialist, ask to see another doctor who has at least the same level of training and expertise and who isn’t a close peer.
If you feel you can’t ask your current doctor, try one of these other ways to get a second opinion:
- Ask your loved one’s insurance provider to recommend a specialist.
- Ask a local clinic for a recommendation.
- Ask a local hospital for a recommendation.
- Search a medical association for a specialist near you.