Making Sense of New Cholesterol Advice

Cholesterol treatment guidelines provide new recommendations to help reduce cardiovascular risks

(RxWiki News) In November 2013, the American Heart Association (AHA) and the American College of Cardiology (ACC) issued guidelines on how to treat high cholesterol that set off a debate in the medical community.

While the guidelines supported commonly held advice about eating healthy and exercising to maintain cardiovascular health, they also recommended discontinuing the targeting of specific cholesterol levels.

To help clear up confusion that the guidelines may have created, the Annals of Internal Medicine recently published a summary of the major recommendations.

"Ask a doctor about best approaches for lowering cardiovascular risks."

Neil J. Stone, MD, chair of the expert panel that wrote the new guidelines and professor of medicine at Northwestern University Feinberg School of Medicine, and his colleagues provided an overview of the eight ACC/AHA recommendations for the treatment of blood cholesterol to reduce atherosclerotic cardiovascular disease (ASCVD) risk in adults.

These recommendations included the following:

The first recommendation was that a healthy lifestyle should be encouraged for everyone. The panel encouraged people to pursue a healthy lifestyle, including eating a healthy diet, exercising regularly and maintaining a healthy body weight.

The next recommendation was to use statins for those at high risk of heart attack, stroke and other cardiovascular events. The panel identified four groups of patients who might reduce the risk of heart disease and cardiovascular events by taking statins to lower LDL (low-density lipoprotein) or “bad” cholesterol. These groups consisted of the following:

  1. Those who already have ASCVD
  2. Those with LDL cholesterol greater than 190 mg/dL
  3. People 40 to 75 years old with diabetes and an LDL cholesterol level of 70–189 mg/dL
  4. People 40 to 75 years old with an LDL cholesterol level of 70 to 189 mg/dL who do not have clinical ASCVD or diabetes but whose estimated 10-year risk of ASCVD is 7.5 percent or higher

Next, the panel called for using statins properly. Dr. Stone and his co-authors also stressed that statins are relatively safe. The panel focused on statins after a comprehensive review of other cholesterol-lowering medications.

“Statins were chosen because their use has resulted in the greatest benefit and the lowest rates of safety issues,” said Neil J. Stone, MD, chair of the expert panel that wrote the new guidelines and professor of medicine at Northwestern University Feinberg School of Medicine, in a press release from November 2013. “No other cholesterol-lowering drug is as effective as statins.”

Commonly used statins are atorvastatin (brand name Lipitor), fluvastatin (brand name Lescol), lovastatin (brand name Mevacor), pravastatin (brand name Pravachol), rosuvastatin calcium (brand name Crestor) and simvastatin (brand name Zocor).

The fourth recommendation encouraged a doctor-patient discussion before starting statin therapy. The scientists urged patients and doctors to discuss the benefits and risks of statins.

Then, the panel recommended starting statin therapy at the right strength. The appropriate intensity of statin therapy needs to be established as well, according to the authors.

Dr. Stone and team also suggested using a newly developed calculator for establishing risk. The guidelines recommended using a “pooled risk equations” calculator to gauge 10-year risk for heart attack or stroke. The calculator takes into account age, sex, race, blood pressure level, current treatment for blood pressure, total cholesterol, HDL ("good" cholesterol), diabetes and smoking history.

The panel also said that doctors and patients should not treat cholesterol to reach targeted goals. Previous guidelines recommended that patients at high risk of heart disease try to reach targeted levels of LDL cholesterol of less than 100 mg/dL. The researchers of this study did not find evidence to support this approach of “treating to goal.”

Lastly, the panel recommended regularly monitoring patients. The panel encouraged a regular review of how patients keep up with diet, exercise, a healthy weight and statin therapy.

"I don't think we should abandon all of the previous guidelines, especially those suggesting aggressive LDL targets for high risk patients," said Jeffrey Schussler, MD, an interventional cardiologist on the medical staff at Baylor Heart and Vascular Hospital and Baylor University Medical Center at Dallas.

"What the new guidelines are doing is focusing and emphasizing two core concepts: First, that high-risk patients should be on statins. Second, that for these high-risk persons these medications are beneficial no matter if you don't make your target cholesterol reduction," Dr. Schussler told dailyRx News.

In a separate but related article in the same issue of the Annals of Internal Medicine, Seth Martin, MD, a fellow at The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, and Roger Blumenthal, MD, director at the Ciccarone Center, applauded the new guidelines for emphasizing “core concepts to rally behind.”

While Drs. Martin and Blumenthal praised the guidelines for encouraging communication between patient and doctor, they also highlighted two areas of controversy — the new risk calculator and the panel’s recommendation to abandon goals for LDL cholesterol.

They said that some studies have shown that the calculator may overestimate cardiovascular risk by 75 to 150 percent. They advised health care providers to seek a “middle ground” when making treatment decisions based on these new guidelines.

In a separate commentary, John Downs, MD, from South Texas Veterans Health Care System in San Antonio, Texas, and Chester Good, MD, from Veterans Affairs Pittsburgh Healthcare System, recognized the controversy surrounding the guidelines, but largely approved of the panel recommendations. They wrote, “The decision to discontinue the treat-to-target approach to lipid management makes sense.”

These articles were published January 28 in the Annals of Internal Medicine.

Review Date: 
January 27, 2014