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editorial

Dispute on cholesterol guidelines harms fight against heart disease

The launch of major new treatment guidelines is never a good time for confusion. Yet that’s been the effect of far-reaching new advice about how to lower cholesterol in order to help patients avoid a first heart attack or stroke. Critics argue that a risk calculator released last week by the American Heart Association and the American College of Cardiology overestimates some people’s risk substantially — by as much as 75 to 150 percent. If true, that could lead to millions of people getting cholesterol-lowering drugs who don’t need them. Meanwhile, until medical experts resolve the uncertainty, people who would genuinely benefit from medication might avoid getting it.

For any health guidelines to work, they must be persuasive. The new recommendations, the first in more than seven years, are a dramatic course correction under which many more Americans would be advised to take cholesterol-lowering drugs, particularly those known as statins. Previously, doctors were urged to prescribe statins based primarily on a patient’s cholesterol levels. That is no longer the case, and the new guidelines don’t even set target levels for LDL, the so-called bad cholesterol. Instead, doctors and physicians are to use the online risk calculator now being called into question. The calculator assesses four risk factors, including age and family health history, to determine whether a patient needs treatment. Following this advice, the guidelines’ writers say, could result in a major reduction in heart attacks, strokes, and deaths.

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But when two Brigham and Women’s Hospital researchers, cardiologist Paul Ridker and biostatistician Nancy Cook, saw the new cholesterol advice last week, they were concerned. Ridker, a leading expert on statins as treatment, had the chance to try out the calculator several months in advance and warned its developers that the tool may overestimate people’s risk by relying on old data. Ridker and Cook used newer data to show the discrepancy. Nonetheless, when the calculator was rolled out, the formula hadn’t changed. That could lead, Ridker and Cook’s research suggests, to the calculator putting a patient’s risk of suffering a heart attack in the next 10 years at more than double what it truly is.

The guideline writers vigorously defend the calculator’s accuracy. “There’s nothing wrong with these equations,” Dr. Donald Lloyd-Jones, who led the panel, told reporters. The American Heart Association has said that the organization will go ahead with the calculator as is.

Missing from this back-and-forth, however, is the fact that heart disease remains the leading cause of death in this country, accounting for 1 in 4 deaths. If the heart association and College of Cardiology stand behind the new recommendations as the means to lowering that fatality rate, the organizations will need to work harder to convince doctors and patients to trust them.

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