One of the most rewarding things I do in my clinic happens on my iPhone.
When I sit down with a middle aged patient to talk about their cardiovascular risk, I open the risk calculator created by the American Heart Association and the American College of Cardiology. I talk my way through as I enter the parameters – age, blood pressure, lipid numbers, smoking history and so on. Then I write down their ten year risk on a piece of paper next to the “ideal” risk for a person that age, for example 8% risk versus ideal 3%.
I explain that statin drugs may lower anybody’s risk by 30-50%, which is more important to consider the higher their risk is, because half of almost nothing is almost nothing.
I also write down the opposite numbers: 92% chance that nothing bad will happen versus 97%. That number, to most patients, seems less dramatic than “almost tripled risk” in the first set of numbers.
Next, I fast forward a few years. Both my patient and Mr. or Ms. Perfect are then older and have a greater risk. I can then also show what the risk would be if they had quit smoking, controlled their blood pressure or developed diabetes during that time.
I write down the new risk numbers with notations of the hypothetical new blood pressure and so on. And inevitably I also end up pointing out that the guideline that accompanies the calculator would have just about every 65 year old, even Mr./Ms. Perfect, take statin drugs. I always get the same incredulous reaction to that one.
Next, I mention the Hale study, which showed that older patients who follow a Mediterranean diet have 50% less cardiovascular disease than people who eat a more typical Western diet. But, of course, maybe the diet choices are also linked to other lifestyle factors.
Lastly, I mention that this calculator does not take family history into consideration.
The conversation this little app generates is, in a way, what medicine today is all about. We have lots of data, but the Art of Medicine is figuring out if and how the statistics apply to an individual patient. And, of course, laying out the options so our patients see them clearly and can decide for themselves.
(For more on lipid guidelines, statins and the Mediterranean diet, check out the video below. More videos at A COUNTRY DOCTOR TALKS.)
A Country Doctor Writes: 
Up until a few years ago the cardiovascular risk factor calculator engaged the interested patient. One cost-effective test is the Coronary Artery Calcium Score (CAC score). When the score is Zero, we agree their genetics and lifestyle are sufficient. When surprisingly high, the score reflects silent disease and the patient is more appropriately given medical attention
Recently had blood work (72F) that showed I had a moderate risk and was prescribed Crestor. I plugged my numbers into the calculator and lowered my age to 69. Now I was low risk and didn’t need a statin. So, the calculator does recommend statins due to age. Yes, risks go up as you age, but risks for most everything goes up, not just CVD risk. Personally I think if you get to 72 without hypertension, diabetes and are normal weight, you should get a gold star and not a prescription for statins. I decided not to take Crestor, which according to the Hope3 study only lowers absolute risk by 1% and work on improving diet instead. In 3 months my HDL went up 11 points to 65 and LDL went down. Still not perfect numbers but that’s ok with me. Doc was ok with my plan to continue with dietary improvements so I’ll just continue being active and eating well.