Seth S. Martin, MD; Roger S. Blumenthal, MD
Financial Support: Dr. Martin is supported by the Pollin Cardiovascular Prevention Fellowship and the Marie-Josée and Henry R. Kravis endowed fellowship. Dr. Blumenthal is supported by the Kenneth Jay Pollin Professorship in Cardiology.
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-2805.
Requests for Single Reprints: Roger S. Blumenthal, MD, Johns Hopkins Hospital, 1800 Orleans Street, Blalock 524C, Baltimore, MD 21287; e-mail, email@example.com.
Current Author Addresses: Drs. Martin and Blumenthal: Johns Hopkins Hospital, 1800 Orleans Street, Blalock 524C, Baltimore, MD 21287.
Author Contributions: Conception and design: S.S. Martin, R.S. Blumenthal.
Analysis and interpretation of the data: R.S. Blumenthal.
Drafting of the article: S.S. Martin.
Critical revision of the article for important intellectual content: S.S. Martin, R.S. Blumenthal.
Final approval of the article: S.S. Martin, R.S. Blumenthal.
Table. The 5 Ps
The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.
David L. Keller, MD, MS, FACP
March 5, 2014
Should we be measuring statin blood concentrations?
Patients who are at risk of adverse events due to atherosclerotic vascular disease (ASVD) are treated with statins, which have been well-proved to reduce these risks. Until now, physicians were told to treat these patients to goals based on blood levels of LDL cholesterol. Now, we are told that the evidence does not support treating to LDL goals, but rather dictates that certain doses of statin be administered, based on the doses which were used in clinical trials.
All medications work by some pharmacological effect. Prior guidelines were based on the assumption that lowering the LDL cholesterol concentration in the blood was the beneficial mechanism. This hypothesis implied that other types of medications should be as effective as statins at reducing adverse ASVD event rates, for equal degrees of LDL-lowering. If this has been disproved, then the new guidelines are reasonable to emphasize statin dose rather than LDL level as the treatment goal.
However, we can and should strive to quantify and normalize our statin treatment for each patient. If the pharmacological benefit of statin therapy is caused by the concentration of the statin in the blood, rather than by blood LDL levels, we should be measuring and monitoring statin levels now, instead of LDL levels. Otherwise, we are treating patients blindly.
A given dose of a statin will result in very different blood concentrations of that statin in different individuals, depending on their renal and hepatic functions, their body mass, their cytochrome genetics, and on other factors. To account for these differences in each unique patient, blood statin concentrations would seem to be required to most precisely maximize the benefits and minimize the risks for each patient.
Martin SS, Blumenthal RS. Concepts and Controversies: The 2013 American College of Cardiology/American Heart Association Risk Assessment and Cholesterol Treatment Guidelines. Ann Intern Med. 2014;160:356–358. doi: https://doi.org/10.7326/M13-2805
Download citation file:
Published: Ann Intern Med. 2014;160(5):356-358.
Cardiology, Coronary Risk Factors, Dyslipidemia, Endocrine and Metabolism.
Results provided by:
Copyright © 2019 American College of Physicians. All Rights Reserved.
Print ISSN: 0003-4819 | Online ISSN: 1539-3704
Conditions of Use