Blog | Friday, December 20, 2013

How you can talk to your doctor about cholesterol

I’m not going to discuss the entire subject of cholesterol in this post, but one part of it: specifically, how to discuss with your doctor how much cholesterol should matter to you.

If you have read any health news recently, you know that the American College of Cardiology and the American Health Association issued new guidelines to help doctors advise patients about cholesterol medications. The new recommendations are accompanied by a calculator of heart risk into which one enters various laboratory and personal characteristics: whether you smoke, have diabetes, have high blood pressure, and the like.

Unfortunately, a kerfuffle has ensued over some errors present in the calculator. Millions of Americans, under the new guidelines, might be recommended to receive cholesterol medications, and this massive expansion of the medicated populace is under dispute.

Putting that aside, however, we will focus here on an even more basic question: how do you know what level of heart risk is important to you? Any recommendations about whether or not to use a cholesterol medication—the old ones and the new ones—depend on the application of calculation to you. The doctor will calculate the risk in the next 10 years that you will have a heart attack, and use that number to decide whether you should be taking a cholesterol medication.

However, that assumption crumbles the harder you press on it. First you should discuss with your doctor whether you are in one of the high-risk categories that places you at significant risk of heart disease in the first place: a family history of early heart disease or stroke; or a history of diabetes in yourself. Perhaps, on the other hand, you are generally healthy and your risk of heart disease is low; this is probably most people. A significant proportion will fall somewhere in the middle.

But even if your risk lies at one of these two extremes, and your doctor is confident in telling you that your risk of heart disease is high (or low), there is one essential point to keep in mind which is underemphasized in all the media coverage of the new cholesterol guidelines:

Whether to take such a medication is still, and always, your decision.

This is not “your decision” in the sense of: go play in traffic, see if I care. Rather, your decision-making must take into account a whole variety of factors, which can be clarified by thinking about the following questions, or discussing them with your doctor:

Cholesterol medications can reduce the rate of heart disease, but there’s a difference between absolute rate reduction and relative rate reduction. If a cholesterol medicine reduces your rate of heart disease by 50%, that sounds great, but it’s less impressive if your 10-year chance of developing heart disease was only 5% to start with. Maybe you can live with a 10-year chance of developing heart disease that’s 5 in 100. So you might ask: “What is my baseline risk of developing heart disease, without a cholesterol medication?”

Cholesterol medications can cause side effects not uncommonly. Some studies cite a rate of 10% for the rate of muscle-related symptoms (this is probably the upper range of the rate, including everything from muscle aches all the way to significant muscle inflammation). You are really the only one who can weigh the chance of side effects to the benefits of the medication. But you might ask, “How would you compare the risks and benefits of this cholesterol medication?”

Finally, it’s important to realize the imperfect nature of all guidelines. A guideline is merely a compendium of recommendations, and a recommendation can only be useful and relevant to you if two things are true: (a) it is based on good scientific evidence; (b) this evidence is relevant to your particular needs, sensitivities, and circumstances. About (a), you should ask your doctor, “How confident are you in the scientific evidence that backs up this recommendation?” Pay particular attention, for example, to how they understand the balance between risks and benefits in the subpopulation (i.e. the risk category) you fall into.

With regard to (b), of course, you are the only one who can make that determination, and no guideline can substitute for your considered, informed decision.

Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews. He is also a poet, journalist and translator in Yiddish and English. This post originally appeared at his blog.