The Skinny on Fats
I knew an old country doctor who ordered lab tests to confirm what he already suspected. Dewey would say it’s more important to treat the whole patient. He used cholesterol as an example. “I refuse to treat a lab test!” he would exclaim. He had dozens of stories of using wit and ingenuity to solve patient problems, most of which didn’t involve lab tests.
Last November the American College of Cardiology and American Heart Association issued new cholesterol guidelines, a major update since the 2004 ATP III (Adult Treatment Panel) report.. These new guidelines seem to have caught up to old country docs by getting rid of target numbers.
According to the experts, there is no evidence to treat to LDL cholesterol targets of less than 100 or 70 mg/dL. Instead, patient groups are identified with appropriate statin therapy recommendations for reducing cardiovascular disease:
- Individuals with clinical artherosclerotic cardiovascular disease
- Individuals with LDL >= 190 mg/dL e.g. with familial hypercholesteremia
- Individuals 40-75 years with diabetes and LDL 70-189 mg/dL and no evidence of artherosclerotic cardiovascular disease
- Individuals not in the above categories but who have an LDL 70-189 mg/dL and a 10-year risk >= 7.5%
If statin therapy guidelines are followed, physicians don’t have to fuss about reaching a particular number. According to cochair of the guidelines Dr. Donald Lloyd-Jones at Northwestern University Feinberg School of Medicine, evidence to treat to a target isn’t there, although LDL is still important. The test is a means, not an end.
Retired family physician Harriet Hall blogging at Science-Based Medicine sums up, “In essence, they switched from treating lab tests to treating patients.” Good old Dewey (he was fond of signing his notes to clinic staff G.O.D.) would agree.
A staff member told a story about a local country doc she telephoned one day to report that lab equipment was down. He said, “I’ve gotten along for forty years without lab tests, I guess I can manage for a few hours.” I sometimes wonder if these doctors are a vanishing breed. I hope not.
NEXT: All The Other Labs Do It