Reprinted from the winter 2024 issue of The Ohio Family Physician.
By: Matthew J. Farrell, MD, The Ohio State University College of Medicine
Cardiovascular disease is the number one killer in the Western world1 and I often believe that most patients recognize this fact. For many years, patients have heard that cholesterol is bad for them and that the primary focus of treatment is to lower their cholesterol numbers as much as possible.
While it is true that patients with a more ideal lipid profile will often have lower rates of cardiovascular disease, I have found that the fixation that some patients have on just their cholesterol numbers can be counterproductive. Instead, I would rather patients focus on the calculation of their overall cardiovascular risk. Typically, I use the atherosclerotic cardiovascular disease (ASCVD) risk calculator provided by the American College of Cardiology.2 I have used this tool on the computer screen in front of patients to show them the various factors that are important for their cardiovascular risk, including, but not exclusively limited to, their lipid profile.
In a typical patient encounter, most often at an annual preventive visit, I will advise the patient that I would like to check their lipids, which most patients recognize as a common screening. I will then explain to the patient that I will use the results of that lab, in addition to several other factors, to calculate their risk of a heart attack or stroke in the next 10 years. I point out that while the cholesterol numbers are important, the patient’s age, sex, smoking history, blood pressure, and so forth must be considered.
Once the lab results return, I can then use the calculator to accurately determine the patient’s cardiovascular risk and make a clinical decision on treatment options, such as starting a statin medication. In my experience, patients are generally familiar with statins as a class of medication, but most patients think that all a statin does is lower their cholesterol numbers. I explain to patients that the statin drug will, in fact, make their cholesterol numbers “prettier,” but I emphasize that is not really the point of taking the medication. Instead, I want the patient to realize that the purpose of the statin medication is to lower their cardiovascular risk, and I can then explain the mechanisms for how that works.
When starting a new medication, patients will often ask how long they need to take it. In the case of cholesterol treatments, I point out that since the medication is lowering their cardiovascular risk, they will need to take it as long as their risk is high. And since one of the major drivers for cardiovascular risk is age, their risk is likely to rise higher with every passing year. Therefore, I will often recommend patients take their treatments indefinitely.
Beyond statin therapy, I also try to impart how a healthy lifestyle can improve cardiovascular risk. I often emphasize to my patients how regular exercise, smoking cessation, eating a well-balanced diet that is rich in whole grains and low in saturated fats, and other unique lifestyle measures are critical for their cardiovascular risk, beyond just what impact those measures might have on their cholesterol numbers.
It is my hope that, over time, patients will get used to the idea that what we should really care about is prevention. I also hope that patients come to realize that lowering cholesterol is a means to that end, but should not be in and of itself the only goal.
References available on the Ohio Academy of Family Physicians website.