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New Guidelines for Cardiac Prevention and Statin Use

New guidelines abandon LDL targets and identifies the four major primary and secondary patient groups who should be treated for statins….

It’s been more than a decade since the Adult Treatment Panel (ATP) issued the third report for the detection, evaluation, and treatment of elevated cholesterol and nine years since those recommendations were updated, but new guidelines from the American College of Cardiology (ACC) and American Heart Association (AHA), developed in conjunction with the National Heart, Lung, and Blood Institute (NHLBI), are now available online in both the Journal of the American College of Cardiology and Circulation.

Gone are the recommended LDL- and non-HDL–cholesterol targets, specifically those that ask physicians to treat patients with cardiovascular disease to less than 100 mg/dL or the optional goal of less than 70 mg/dL. According to the expert panel, there is simply no evidence from randomized, controlled clinical trials to support treatment to a specific target. As a result, the new guidelines make no recommendations for specific LDL-cholesterol or non-HDL targets for the primary and secondary prevention of atherosclerotic cardiovascular disease.

Instead, the new guidelines identify four groups of primary- and secondary-prevention patients in whom physicians should focus their efforts to reduce cardiovascular disease events. And in these four patient groups, the new guidelines make recommendations regarding the appropriate "intensity" of statin therapy in order to achieve relative reductions in LDL cholesterol.

The four major primary- and secondary-prevention patient groups who should be treated with statins were identified on the basis of randomized, controlled clinical trials showing that the benefit of treatment outweighed the risk of adverse events. The four treatment groups include:

  • Individuals with clinical atherosclerotic cardiovascular disease.
  • Individuals with LDL-cholesterol levels >190 mg/dL, such as those with familial hypercholesterolemia.
  • Individuals with diabetes aged 40 to 75 years old with LDL-cholesterol levels between 70 and 189 mg/dL and without evidence of atherosclerotic cardiovascular disease.
  • Individuals without evidence of cardiovascular disease or diabetes but who have LDL-cholesterol levels between 70 and 189 mg/dL and a 10-year risk of atherosclerotic cardiovascular disease >7.5%.

In those with atherosclerotic cardiovascular disease, high-intensity statin therapy—such as rosuvastatin (Crestor, AstraZeneca) 20 to 40 mg or atorvastatin 80 mg—should be used to achieve at least a 50% reduction in LDL cholesterol unless otherwise contraindicated or when statin-associated adverse events are present. In that case, doctors should use a moderate-intensity statin. Similarly, for those with LDL cholesterol levels >190 mg/dL, a high-intensity statin should be used with the goal of achieving at least a 50% reduction in LDL-cholesterol levels.

For those with diabetes aged 40 to 75 years of age, a moderate-intensity statin, defined as a drug that lowers LDL cholesterol 30% to 49%, should be used, whereas a high-intensity statin is a reasonable choice if the patient also has a 10-year risk of atherosclerotic cardiovascular disease exceeding 7.5%.

For the individual aged 40 to 75 years without cardiovascular disease or diabetes but who has a 10-year risk of clinical events >7.5% and an LDL-cholesterol level anywhere from 70 to 189 mg/dL, the panel recommends treatment with a moderate- or high-intensity statin.

In the primary-prevention-therapy decisions, the expert panel insisted that the patient and the physician have a discussion to determine what the benefits and risks are specifically for that patient. This discussion should focus on the patient’s characteristics and preferences to determine the best therapy.

To assess the patient’s degree of risk, a new global risk assessment tool was developed by the expert panel. The new cardiovascular risk score is designed to assess the risk of an initial cardiovascular event and includes participants from racially and geographically diverse cohorts such as the Framingham Heart Study (FHS), the Atherosclerosis Risk in Communities (ARIC) study, the Coronary Artery Risk Development in Young Adults (CARDIA), and the Cardiovascular Health Study (CHS). The new pooled cohort equations predict the future risk of cardiovascular disease and also stroke.

Treating patients with a calculated risk exceeding 7.5% is a lower threshold for treatment than previous guidelines and likely expands the use of statins to millions of patients who would not have otherwise been treated under the ATP III guidelines.

In addition to identifying the four statin groups, the focus on intensity rather than goals, and the new global risk assessment equations for primary prevention, the new cholesterol guidelines also make recommendations on safety and provide guidance on the role of biomarkers and other noninvasive tests.

In the new guidelines, the ACC/AHA state that in selected individuals who don’t fit into any of the four groups, additional factors can be considered if the decision to start statin therapy is unclear. The factors include family history of premature atherosclerotic cardiovascular disease in a first-degree relative, high-sensitivity C-reactive protein (CRP) >2 mg/L, the presence of calcification on a coronary artery calcium (CAC) scan, and an ankle-brachial index <0.9.

The writing committee also states that the new guidelines are not intended to provide a comprehensive approach to managing lipids and that many unanswered questions remain. These future questions, such the use of non-HDL cholesterol in decision-making, the role for treating high triglycerides, and whether treating markers such as apolipoprotein B or LDL particles is useful, will hopefully be examined in future randomized trials and incorporated in future guidelines.

Practice Pearls:
  • The American Heart Association (AHA) and American College of Cardiology (ACC) released four new guidelines dealing with the prevention of cardiovascular disease (CVD) by better assessing risk and by managing cholesterol, lifestyle, and weight.
  • The guideline on managing blood cholesterol diverges from previous guidance by moving away from hard treatment targets for LDL and non-HDL cholesterol, and focusing instead on identifying the appropriate intensity of therapy for a particular patient in order to reduce his or her risk, in combination with a heart-healthy lifestyle.

2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults VIEW GUIDELINE HERE

ACC/AHA Press Release Nov, 2013