The cardiologists are now discussing a new set of guidelines about cholesterol.
I thought it worth posting since many readers are on treatment.
The idea is reducing heart disease risk, the leading cause of premature death and disability in America.
Commentary December 31, 2013
2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults
Peter Libby MD
The cardiovascular community has long-awaited new prevention guidelines. After many years of conscientious work, in June 2013 the National Heart, Lung and Blood Institute (NHLBI) announced that it would limit its participation to supporting and producing systematic reviews regarding prevention. In August of 2013, the NHLBI, American Heart Association (AHA), and American College of Cardiology (ACC) jointly announced that the ACC and AHA would jointly assume responsibility for the prevention guidelines. The community was, therefore, very gratified when four sets of guidelines were released in November of 2013.
With respect to the cholesterol guidelines, the previous Adult Treatment Panel III (ATP III), already some dozen years old, was based on then–emerging, large-scale randomized clinical trials and opinion of a seasoned and knowledgeable group of experts. The panel that produced the 2013 cholesterol guidelines hewed to an evidence-based approach, enriched by clinical trial results that have accumulated since ATP III.
On the basis of current evidence, the group defined four statin benefit groups.
1. All who have clinical atherosclerotic cardiovascular disease and thus fall into the “secondary prevention” category
2. Those with low-density lipoprotein (LDL) cholesterol ≥ 190 mg/dL without a secondary cause,
such as a high intake of saturated or trans fats or various drugs or diseases
3. Individuals with diabetes without established cardiovascular disease aged 40–75 years with LDL cholesterol between 70 and 189 mg/dL
4. Those without established ASCVD without diabetes aged 40–75 years with LDL cholesterol from 70–189 mg/dL with a calculated ASCVD ≥ 7.5%.
An online risk calculator was provided to aid clinicians and patients in calculating their risk. The panel recommended that clinicians and patients engage in a risk–benefit conversation before initiating statin therapy rather than relying solely on numbers emerging from a risk calculator or preordained categories—a patient-centered approach. The panel emphasized that medications do not replace a healthy lifestyle.
Summary of the Four Statin Benefit Groups Described in the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce ASCVD in Adults
Clinical ASCVD “secondary prevention”
LDL-C > 190 mg/dL without secondary cause (eg, high saturated/trans fats, drugs, certain diseases)
Primary prevention with Diabetes–Age 40-75 years–LDL-C, 70–189 mg/dL
Primary prevention without diabetes–Age 40-75 years–LDL-C, 70–189 mg/dL, estimated ASCVD risk ≥ 7.5%
Adapted from: Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published online ahead of print November 7, 2013]. J Am Coll Cardiol. doi: 10.1016/j.jacc.2013.11.002.
Perhaps the most surprising and difficult for many to comprehend was eliminating LDL targets for monitoring therapy. The panel noted that existing randomized controlled trials did not use designs that titrated therapy to a particular target. The guideline authors, therefore, judged that the current evidence does not support the practice of adjusting therapy to achieve a particular target level. This view contrasts strikingly with the former National Cholesterol Education Project and ATP III recommendations, which urged the public to “know their number” and the medical community to strive to reach a particular LDL level in patients in various risk categories.
Another important change in the new cholesterol guideline is the focus on statins rather than other categories of lipid-modulating drugs, including the fibrates, ezetimibe, and nicotinic acid. The panel pointed to the lack of evidence derived from well-conducted and sizable clinical trials that support improved cardiovascular outcomes in patients already treated with statins compared with other classes of drugs that modulate lipid levels.
The panel also provided some useful practical guidelines regarding management of perceived muscle toxicity attributed to statins, a major concern of many patients and practitioners.
The new guidelines have engendered considerable comment and discussion, and some controversy. Issues by commentators included the strength of the evidence supporting a net benefit for widespread statin use, particularly in primary prevention and in women. Others have questioned the calibration of the new risk instrument provided by the guidelines.
The new guidelines presented an enormous step forward as they include primarily evidence-based recommendations. Their implementation should improve cardiovascular health by promoting evidence-based practice. While many practitioners and the public may have initial discomfort with the abandoning of LDL target goals, the rationale presented by the panelists is quite compelling.
I think it is a refinement. Highlighted the important things.