ArcaMax

DEAR DR. ROACH: I am a 69-year-old female. Recently, I had some blood work done, and my doctor decide to put me on Lipitor based on my LDL results. After reading the side effects, I am hesitant to take the drug. My LDL level is 128 mg/dL, my HDL is 49 mg/dL, and my total cholesterol is 192 mg/dL. Over the years, my numbers go up and down. I feel that if I controlled my diet better, I could get my LDL level down without medication. Is this possible? -- Anon.

ANSWER: Because all drugs have the potential for harm, it's always good to take a clear-eyed look at the risks and benefits of a medicine, especially one like Lipitor that is designed to prevent future problems (a heart attack or stroke) rather than treat present symptoms.

The critical endpoint is not the cholesterol; it's your risk for a "cardiovascular event," which specifically means death, heart attack or stroke in this case. Cholesterol and blood pressure are some of the most important risk factors, but your diet, exercise, family history, smoking use, and even nontraditional risk factors (like stress, sleep, and close relationships with your family and friends) also impact your risk of heart disease.

Improving your diet is always a good idea no mater your cholesterol levels, because a healthy diet has independent benefits on the heart and in many other conditions, as does regular exercise.

When considering starting a medicine like atorvastatin (Lipitor), I start with your baseline risk of a cardiovascular event. I use the PREVENT calculator (tinyurl.com/preventcalc) from the American Heart Association, which uses the most up-to-date data to provide your 10-year risk based on your risk factors.

Assuming you have normal blood pressure, kidney function, and BMI, the model predicts that you have an 8.8% chance of a cardiovascular event in 10 years. These are pretty good odds, a better-than-91% chance that your heart will be fine when you are 79. Your cholesterol isn't bad, and most of your risk just comes from the fact that you are 69. Age is the major risk factor for heart disease.

With treatment from a drug like Lipitor, your risk would drop to about 7%, or a 93% chance that everything will be fine. You should ask yourself, "Is this worth it to me?" Many readers will say "no," while some will say "yes." You are at a level where there isn't a right answer for everyone, which is why I like to give a person as much information as possible to help them make their decision.

You also need to consider the possible harm from taking Lipitor or another statin. You have probably read that some people will notice muscle aches, which is true. However, in studies where people don't know whether they are taking a statin, people were just as likely to say that they had muscle aches while taking an inactive placebo pill.

However, in clinical practice where people expect muscle aches, as many as 15% of people notice them. Many of these symptoms are due to expectations rather than a side effect of the medicine. True muscle damage from statins is fortunately rare -- less than 1 person per 10,000 who take the medicine for a year.

The vast majority of people who start statins to reduce the risk of heart disease tolerate the medication very well. If your doctor treats 50 people like you, on average, these medications will prevent one cardiovascular event. That might be you.

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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.

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