As Physicians, We Still Don’t Get It


I have read the AHA/ACC Statin Guidelines, as well as many of the tidal wave of articles printed both for and against the new recommendations, most written by equally respected expert physicians.

Is it just me or has something drastically changed with the practice of medicine in the U.S.?

I realize that medicine has transitioned from a most noble profession to a business, but it is mind boggling to notice such a wide diversity of expert opinions that differ and contradict each other. Most of those in favor of the new recommendations are cardiologists. After all, the American College of Cardiology and American Heart Association put out the recommendations. One prominent cardiologist even wrote he was surprised at the standard therapy for those 75 or older, with no statin recommendation for primary prevention in the elderly. Others, including the American Association of Clinical Endocrinologists, are so opposed to the new guidelines, that they will not endorse or follow the new recommendations.

If this isn’t concerning enough, two months later, the new BP Guidelines from JNC-8 were released. Raising of target BP to a systolic of 150mmHg and the elimination of previous target systolic pressure of 130mmHg in diabetics and those with chronic kidney disease. Most controversial and embarrassing still, was the defection of 5 of the 14 members that formed the panel, each of whom came out in opposition to the conclusions after its release.


Let’s forget about the methodology used to create the guideline. Forget about the recommendations, and forget about the reasons why so many experts are in disagreement. What I see as the real issue is a complete shift in what is important to us as physicians.

It seems that there is an obsession with guidelines. We have so many guidelines that there is a guidelines clearinghouse to store them. There is also concern with the way guidelines are developed. A process with little or no transparency, made up of experts from a diverse body of special interests whose goal it seems is self-promotion for himself or herself or the organization they represent.

As a practicing physician, I am guide-lined to death. What’s worse is that very few physicians individualize the recommendations as they should, instead applying them equally to all patients, in a “one size fits all” model.

A serious problem arises for all of us when the recommendations by one medical group are not recognized or accepted by another medical group.


When there is disagreement and opposition among the members of the guideline panel that releases recommendations anyway, then in my opinion we have a severely damaged and broken system.

We have experts that can’t agree on much and the patients and physicians who don’t know what to believe in or who to trust.

“First do no harm.” Maybe guideline panel members should continuously remind themselves of that phrase while they are formulating new guidelines.

It seems that in medicine there are too many “experts” giving too many recommendations that only cause confusion. It’s a disservice to patients and physicians. It needs to stop before we loose what little credibility we have left as physicians.

Science fails medicine not through lack of competence, but through lack of vision. Not for the lack of curiosity, but for the limit of things we are curious about. Not for the lack in the ability to investigate, but for the narrowness of the scope of things it is willing to and patient

I am still waiting for the day that guidelines are published, that deal with the cause of chronic disease instead of the treatment. When all medical organizations, health groups and wellness stakeholders can unite in agreement demanding better quality and a more affordable food supply for the entire U.S. population. We need to start subsidizing organic produce and farming, stop the routine use of antibiotics and hormones in livestock, limit chemicals in our foods and improving the water supply. We should have nutrition education that starts in elementary school and we should begin reinstating physical education periods. This is what is needed, not more guidelines that push more drugs on a country overdosing in drugs.

This isn’t being an idealist, this is being a responsible physician.

Despite all the guidelines published and the increased use of statins, we spend $60 billion a week in healthcare and all we have to show for it is being in 46th position in healthcare outcomes and quality, behind Iran and ahead of Serbia.

Maybe its time we remember to put patients ahead of other interests.

This article has been written by:

Jorge Bordenave MD FACP ABIHM

Integrative Cardiologist

Miami Integrative Medicine

OPINION: New AHA/ACC Statin Guidelines

statinsI am greatly concerned with the new statin guidelines recently released by the American Heart Association and the American College of Cardiology during the yearly Scientific Sessions held in Dallas this November. Guidelines introduced to the public with great fanfare, and covered by all National media outlets.

These guidelines take healthy people and input certain risk factors that include age, body weight, smoking history, family history of heart disease, blood pressure and cholesterol levels to determine future cardiovascular (CV) risk. Those that are found to have a CV risk of 7.5% or greater, in the following 10 years would be candidates for statins. (Statins were first introduced in 1987, and over the years, their use has increased. The annual expenditure in 2000 on statins: $7.7 trillion, by 2007: $20 billion). These medications help reduce the amount of cholesterol and LDL (so-called bad cholesterol) in the blood. It is believed however, that statins work in decreasing heart disease because they decrease the degree of inflammation. An effect is given the name pleotrophic effect.

Under the new guidelines, an additional 31 million people would meet criteria for these drugs. Currently, about 15% of all adults in the U.S. take statins and the new guidelines would double it to around 33%. Generalizing treatment to a wide cross section is of concern, because the likelihood of success or failure of a treatment is not identical in all individuals treated, because therapy is not the only determinant of outcome.


It is this continued reliance and focus on drugs that concerns me. I am also concerned and confused with the frequent changes, recommendations and mixed messages made by the medical establishment. How often do we read a medical “expert” recommending one thing, only to have another “expert” recommend something completely opposite, contraindicating the first expert? In a country with so many “experts,” it’s no wonder why patients (myself included) don’t know who or what to believe.

Are we really so sure we should proceed to double the number of U.S. adults on statins as suggested by the new guidelines? Can we be so sure that the benefits of this class of medicines outweigh the risks? We know that the use of statins short-term has side effects in some patients, but what happens after 10 or 20 years of use?

cholesterolCholesterol is not a villain. The absorption of vitamins and minerals including vitamin D, is dependent on cholesterol, which is why our bodies produce it. Multiple studies have shown that statin users have higher rates of cataract formation, increased muscle pains, increased musculoskeletal injuries, reduced blood levels of vitamin D, reduced levels of CoQ10, just to name a few side effects. Most importantly, statins may worsen and possibly cause diabetes. Nevertheless, in one of the ironies we have come to expect from modern medicine, the new AHA/ACC statin guidelines recommend statins for most diabetics.

I have nothing against statins. As a cardiologist, I prescribe statins when needed. What I am against is the indiscriminate use and abuse of not just statins but of all medications and an ever-increasing reliance of medications for everything that ails us.

I will continue to use statins as I do presently. In men younger than 75 years with coronary heart disease, including acute coronary syndrome, chest pain (angina), in those who have had heart surgery (bypass) or stents. People with hereditary hypercholesterolemia should also be considered for statin use. These are the groups that have been shown to get the most benefit from this class of drug. Their use in diabetic women and people with strokes (although current indications) is controversial.

Studies have shown that there is no reason or benefit for the elderly to be on long-term statin treatment. Low cholesterol levels in people over the age of 75, has been associated with decreased cognitive function. Maybe it’s because 25-30% of our brain is made up of cholesterol and cholesterol is essential for many metabolic functions including the production of hormones. However, there are even other medical “experts” who have suggested that it would be a good idea to start giving statins to children.

I find the reliance on medications that have potent side effects to be ongoing failure of the U.S. healthcare system, the costliest healthcare system in the world that only manages a quality and efficiency ranking of 46, behind Iran and ahead of Serbia. It is time to end the “pill for every ill” mentality of disease care synonymous with U.S. health care and make a radical shift back to using common sense and reasoning.

saladInstead of prescribing more drugs, we should be educating and stressing to the general public the importance and need for lifestyle and nutritional change first. The same inflammation and conditions that causes the elevated cholesterol levels that is treated with statins, are caused by and therefore can also be limited and controlled by diet and improved nutrition.

I find it interesting that the dietary advice of 40 years ago, which stressed the importance of eating minimally processed foods, avoidance of artificial sweeteners, selection of meats from organically raised animals and not industrially produced variety, went directly against the recommendations of the experts of that time.

I’ll continue to individualize treatment, educating my patients on the importance of food, exercise and lifestyle and prescribing drugs only when appropriate. I doubt future studies will find anything contradictory with this approach.

Jorge Bordenave, MD FACP ABIHM
Coral Gables, Florida (11-15-2013)
Integrative Cardiologist
Assistant Clinical Professor of Medicine, Herbert Wertheim College of Medicine FIU
Cardiology Lecturer IM and FP Residency Program

Published by Axiom Health Care Marketing