A Mayo Clinic task force has offered "challenges" to some of the controversial heart-health recommendations made by the American Heart Association and American College of Cardiology.
"We didn't try to override the AHA recommendations. We didn't try to say, well, we are wrong they are right," saidMayo director of Preventive Cardiology Dr. Francisco Lopez-Jimenez.
The ACC and AHA updated their guidelines for overall heart-disease risk last year, including cholesterol treatment and heart risk.
Most controversial, according to a 2013 CNN.com article, was the recommendation that a "much broader population" take cholesterol-lowering stations, despite side effects like "muscle pains and soreness, a potential moderate increase in liver disease and a risk for developing Type 2 diabetes."
Mayo, however, announced in August that the clinic task force "concludes, based on current evidence, that not all patients encouraged to take cholesterol-lowering medications, such as statins, may benefit from them and that the guidelines missed some important conditions that might benefit from medication."
That could leave many patients scratching their heads.The guidelines are important because they can help prevent heart attacks and strokes.
"We are trying to give a more individualized approach," Lopez-Jimenez said. The Hospital Association guidelines, he said, make recommendations based on risk.
"If the formula gives you a risk, even if you have no history of heart disease or diabetes, you qualify for cholesterol medicine," Lopez-Jimenez said. "We believe, for an individual who has perfectly normal, low cholesterol, there is actually no evidence to prove that that person is going to benefit from cholesterol medicines."
Medicine as first option?
The AHA recommendations, he said, suggest that patients should be prescribed medicine and then offered counseling about healthy lifestyle changes. Mayo's task force instead recommends, for many people, trying lifestyle and diet changes first.
"We believe that in some patients, especially those who are motivated, especially those whose risk is not excessively high, even if they have a high cholesterol, it might be important to give it a try through lifestyle and see how things go," Lopez-Jimenez said. "We have seen patients in our practice who actually get very faithful, start exercising, follow a healthy diet and the cholesterol goes down, blood pressure goes down, they lose weight and, after we reassess the risk three months later, the risk is actually much lower than what it was originally. So that patient might not need to be on a cholesterol medicine for life."
Shared decision-making is essential, he said, which the AHA points out. But, he said, the AHA guidelines promote use of medicine as a first line of action rather than a second step if diet and exercise changes are ineffective. The Mayo task force prefers that risks and benefits of medication be fully discussed with the patient so the patient can decide, in collaboration with the health provider, whether to first try health lifestyle changes.
At Mayo, clinicians use " shared decision-making" aids that show online if 100 patients take a cholesterol-lowering medicine for 10 years, "this many patients will have a heart attack, this many patients will not have a heart attack." The same is shown for 100 patients who do not take cholesterol-lowering medicine.
If after 10 years, two heart attacks were prevented, Lopez-Jimenez said, "some patients might say, wow, that's nothing." Others might figure it's worth the potential side effects if they happen to be among those who would have a heart attack prevented. Some patients would take the medicine if only a single patient out of 100 avoids a heart attack.
"The patient becomes part of the decision," Lopez-Jimenez said.
Not completely critical
The Mayo task force is not wholly critical of the AHA and ACC recommendations -- and in fact offered some praise for the difficult work they did.
Dr. Iftikhar Kullo, risk-assessment task force chairman, said the two national panels "did a wonderful job" based on evidence.
"This is a commendable job. It's done by experts, our own peers from our own societies. They've done a lot of work," Kullo said.
But Mayo recognizes that the AHA and ACC recommendations are guidelines that need to be adapted "to do what's best for our patients."
Mayo preventive cardiologists reviewed studies carefully.
Also, Kullo said, "we have certain expertise that may not be available nationwide." The Mayo group circulated its findings and made revisions as task force members from Mayo nationally gave feedback until a consensus was reached.
Family history "fell out of their equation" when the AHA/ACC guidelines were written because many of the 25,000 patients in studies reviewed didn't have family histories included. That left a recommendation that suggests taking a family history as a second step "if you're not sure what's to be done" as a health provider.
"That doesn't make sense because family history is part of our physical examination and history. It's a very key part of that interaction between a physician and a patient," Kullo said. "And it has significant utility, particularly in preventive cardiology." It allows identification of family members who may be at risk but have not yet sought medical attention, he said.
"That's an example of where we differ with the recommendations. We're saying, no, we should take a family history," he said.
The task force recommendations were submitted for publication to Mayo Clinic Proceedings.There's a lot of good things Mayo's task force agrees with. Patients, for example, should ask their doctors "What is my number for heart-attack risk? What is my probability?" Patients should also volunteer their family history if the doctor doesn't ask about it.
If it's unclear what the risk is, Kullo said, there are tests that include CT scan for heart calcium, leg circulation tests, and blood test for C-reactive protein. Not mentioned by the AHA/ACC are a carotid ultrasound test of neck arteries to look for plaque formation, arterial-stiffness testing and lipo-protein A test to check for a blood product that might lead to plaque formation.
If you don't know what to do, because there's too much confusing information, Kullo said to discuss your concerns with your doctor.
The idea, said Mayo spokeswoman Traci Klein, is to provide help for physicians elsewhere in the country because Mayo Clinic is believed the first to review the 2013 AHA and ACA recommendations so thoroughly.