The question of statins

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Illustration: C R Sasikumar Illustration: C R Sasikumar
SummaryRecent American guidelines recommend statins to prevent heart attacks without monitoring lipid levels. However, doctors have urged caution due to the many side effects of these drugs.

Should statins — drugs that lower bad cholesterol — be prescribed in high doses to people with low to moderate risk of heart attacks to prevent such episodes? For nearly two weeks now, the cardiology world in the US has been split wide open over the first new guidelines for prevention of cardiovascular diseases in a decade issued jointly by the American College of Cardiology (ACC) and the American Heart Association (AHA) on November 12. The guidelines recommended statins in high doses as the one-stop shop solution for controlling cardiac episodes for everybody aged between 40 and 75 years.

These new rules, according to critics, would add around 30 million Americans to the list of people who can be prescribed statins. However, many have said the guidelines need further evaluation before implementation because statins have side effects such as muscle pain, kidney and liver dysfunction, among others.

The other controversy in the guidelines has been sparked by a proposed new risk assessment tool for cardiac diseases, a shift from the Framingham risk calculator used by most practitioners over the last decade. This tool combines factors including, lifestyle, obesity, diet, smoking and alcohol consumption, apart from cholesterol levels to assess the risk of cardiac diseases. It has been criticised by a former president of the ACC in a comment published in the journal Lancet this week. The guidelines have also discounted any need to monitor levels of lipids as targets to prescribe statins. Till now, the level of lipids was considered the gold standard while deciding statin dosage.

Just a day after the guidelines were released, two cardiologists from the Harvard Medical School — Dr Paul Ridker and Dr Nancy Cook — said their reservations had not been taken into account in the final release even though they were invited to review the guidelines by the National Heart, Lung, and Blood Institute a year ago. In a comment published in Lancet after the guidelines were released, Dr Ridker and Dr Cook said that the new risk assessment tool “systematically overestimated” cardiovascular risks, and could therefore lead to “overtreatment of a substantial fraction”.

The authors of the guidelines have since rushed to defend their recommendations. During the annual conference of AHA organised in Dallas last week, Reuters quoted Dr Sidney Smith of the University of North Carolina as saying, “We intend to move forward with the implementation of these guidelines... If we think there

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