(Nov. 12, 2013) — The American College of Cardiology and the American
Heart Association today released a new clinical practice guideline for
the treatment of blood cholesterol in people at high risk for
cardiovascular diseases caused by atherosclerosis, or hardening and
narrowing of the arteries, that can lead to heart attack, stroke or
death.
The guideline identifies four major groups of patients for whom
cholesterol-lowering HMG-CoA reductase inhibitors, or statins, have the
greatest chance of preventing stroke and heart attacks. The guideline
also emphasizes the importance of adopting a heart-healthy lifestyle to
prevent and control high blood cholesterol.
“The new guideline uses the highest quality scientific evidence to focus
treatment of blood cholesterol on those likely to benefit most,” said
Neil J. Stone, MD, Bonow professor of medicine at Northwestern
University Feinberg School of Medicine and chair of the expert panel
that wrote the new guideline. “This guideline represents a departure
from previous guidelines because it doesn’t focus on specific target
levels of low-density lipoprotein cholesterol, commonly known as LDL, or
‘bad cholesterol,’ although the definition of optimal LDL cholesterol
has not changed. Instead, it focuses on defining groups for whom LDL
lowering is proven to be most beneficial.”
The new guideline recommends moderate- or high-intensity statin therapy for these four groups:
• Patients who have cardiovascular disease;
• Patients with an LDL, or “bad” cholesterol level of 190 mg/dL or higher;
• Patients with Type 2 diabetes who are between 40 and 75 years of age; and
• Patients with an estimated 10-year risk of cardiovascular disease of
7.5 percent or higher who are between 40 and 75 years of age (the report
provides formulas for calculating 10-year risk).
In terms of clinical practice, physicians can use risk assessment tools
in some cases to determine which patients would most likely benefit from
statin therapy, rather than focusing only on blood cholesterol to
determine which patients would benefit.
“The likely impact of the recommendations is that more people who would
benefit from statins are going to be on them, while fewer people who
wouldn’t benefit from statins are going to be on them,” Dr. Stone said.
Doctors may also consider switching some patients to a higher dose of
statins to derive greater benefit as a result of the new guidelines.
The guideline was prepared by a panel of experts based on an analysis of
the results of randomized controlled trials. The panel was charged with
guiding the optimal treatment of blood cholesterol to address the
rising rate of cardiovascular disease, currently the leading cause of
death and disability in the U.S.
The panel chose to focus on the use of statins after a detailed review
of other cholesterol-lowering drugs. “Statins were chosen because their
use has resulted in the greatest benefit and the lowest rates of safety
issues. No other cholesterol-lowering drug is as effective as statins,”
said Dr. Stone. He added that there is a role for other
cholesterol-lowering drugs, for example, in patients who suffer side
effects from statins.
The report also stresses the importance of lifestyle in managing
cholesterol and preventing heart disease. “The cornerstone of all
guidelines dealing with cholesterol is a healthy lifestyle,” said Dr.
Stone. “That is particularly important in the young, because preventing
high cholesterol later in life is the first and best thing someone can
do to remain heart-healthy. On the other hand, if someone already has
atherosclerosis, lifestyle changes alone are not likely to be enough to
prevent heart attack, stroke, and death, and statin therapy will be
necessary.”
In addition to identifying patients most likely to benefit from statins,
the guideline outlines the recommended intensity of statin therapy for
different patient groups. Rather than use a “lowest is best” approach
that combines a low dose of a statin drug along with several other
cholesterol-lowering drugs, the panel found that it can be preferable to
focus instead on a healthy lifestyle along with a higher dose of
statins, eliminating the need for additional medications.
“The focus for years has been on getting the LDL low,” said Dr. Stone.
“Our guidelines are not against that. We’re simply saying how you get
the LDL low is important. Considering all the possible treatments, we
recommend a heart-healthy lifestyle and statin therapy for the best
chance of reducing your risk of stroke or heart attack in the next 10
years.”
The guidelines are intended to serve as a starting point for clinicians.
Some patients who do not fall into the four major categories may also
benefit from statin therapy, a decision that will need to be made on a
case-by-case basis.
The expert panel that wrote the report was convened by the National
Heart, Lung, and Blood Institute of the National Institutes of Health.
At the invitation of the NHLBI, the American Heart Association and
American College of Cardiology assumed the joint governance, management
and publication of this guideline, along with four other prevention
guidelines, in June. Committee members volunteered their time and were
required to disclose all healthcare-related relationships, including
those existing one year before the initiation of the writing project.
The full text of the report, “2013 ACC/AHA Guideline on the Treatment of
Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in
Adults,” will be published in future print issues of the of the Journal
of the American College of Cardiology and the American Heart
Association’s journal Circulation. It will also be accessible on
the ACC
(http://content.onlinejacc.org/article.aspx?doi=10.1016/j.jacc.2013.11.002)
website and AHA
(http://circ.ahajournals.org/lookup/doi/10.1161/01.cir.0000437738.63853.7a).
For more information, visit www.cardiosource.org.
