New Cholesterol Guidelines
New Cholesterol Guidelines: What Should You Know?
by Gerald E. Pytlewski, DO, FACC, FACP, Associate Chief of Cardiology, St. Luke's University Health Network, Diplomate of the American Board of Clinical Lipidology and member of St. Luke's Cardiology Associates
Bethlehem, PA (12/04/2013) - Updated guidelines for treatment of blood cholesterol recently were published in the American Heart Association (AHA) medical journal, Circulation. Tremendous interest was generated among doctors waiting for new recommendations about treating patients with high cholesterol. The report was written by an expert panel of the AHA and the American College of Cardiology, supported by the National Blood and Lung Institute.
Elevated blood cholesterol is an important risk factor leading to plaque developing in arteries, that if left untreated, can lead to a heart attack or stroke. Knowing the most up-to-date treatment of high cholesterol is vitally important for physicians to know for this reason.
The last report, published in 2002 and updated partially in 2004, was the last full set of instructions for physicians to treat this significant risk factor. Developed by a panel of experts, these recommendations were designed to educate physicians on blood cholesterol treatment based on clinical studies of patients treated with cholesterol lowering drugs, particularly statins (such as Lipitor or Zocor).
The last report strongly advised physicians to lower LDL (or “bad”) cholesterol levels in high risk patients to 70 mg/dl or below, primarily with statin drugs. LDL (Low Density Lipoprotein) cholesterol is the most common form of cholesterol causing artery blockage. Statins were chosen as first line drugs because of their effectiveness in reducing heart attacks and strokes in medical studies.
Recommend Reducing LDL by 50%
The new report, published on-line November 12, 2013, surprisingly removed target numbers for LDL. Instead, the panel recommended that LDL be reduced by 50 percent or greater, primarily with statin drugs. The report also introduced a new risk score that measures patients' other risk factors and produces a percent risk of a heart attack within ten years.
High-risk people were identified in four key groups:
1. Patients with known heart disease
2. Patients with diabetes
3. Patients with a 7.5 percent or greater 10 year chance of a heart attack based on the new risk score
4. Low risk patients with very high total cholesterol
The decision to eliminate specific target numbers was based on the fact that the earlier goals never were the primary focus of any clinical study. While the “lower the better” theory regarding bad cholesterol may be generally true, a well-treated patient with an LDL level of 78 mg/dl may have less risk than a patient with LDL of 68 mg/dl who is not properly managed. The panel reinforced that controlling other cardiac risk factors, such as smoking and high blood pressure, together with cholesterol, is the best treatment. In addition, “chasing” cholesterol target numbers may lead to overtreatment with medication, possibly causing unwanted side effects.
Reaction from the Medical Community
The new guidelines have prompted a swift reaction from the medical community. Supporters praise what they feel is a simpler approach to cholesterol reduction as well as a clear identification of high-risk patient groups. They also feel that more patients who may benefit from statin drugs will be prescribed them, while patients at lower risk can avoid taking them.
Critics are concerned about the reliability of the new risk score and the potential risks of the high doses of statins needed to achieve the recommended 50 percent reduction.
When examined carefully, however, much of what is recommended does not change. Treatment for high-risk patients nearly always requires lowering LDL cholesterol by 50 percent to meet even the previous recommendations. The majority of current treatment focuses on statin drugs, adding other agents only when needed to achieve this aggressive goal. I support the proposals in the new report and believe they will result in more people being appropriately treated.
What does it mean for the general public, particularly those challenged by heart disease, the world's number 1 killer of men and women? If you are at high risk, little will probably change.
I believe the new guidelines, while imperfect, present a logical and simplified approach to a very common and often complex health issue. Remember, the ultimate goal - significantly lowering cholesterol, having a healthy, active lifestyle and managing other risk factors - is to reduce the impact of cardiovascular disease on the long term health of our patients. This is a goal of patient treatment that will never change.