The American Heart Association and the American College of Cardiology surprised many doctors and patients by issuing controversial new guidelines for reducing cardiovascular risk factors, especially focusing on the treatment of cholesterol levels. Simply put, the advice is now to reduce the targeting of specific levels of LDL and HDL (bad and good cholesterol, respectively) and view the patient s overall CVD risk in totality. This new procedure involves an algorithm-based risk assessment which includes LDL levels, and adds lifestyle factors such as smoking, weight and diet, as well as other factors such as diabetes and high blood pressure.
In fact, the recommendations are based upon an extremely thorough investigation of hard evidence-based studies carried out over the past decade or more. The advisory panel a joint effort of the two groups and published simultaneously in the Journal of the American College of Cardiology and Circulation is 77 pages in length (followed by over 100 references), accompanied by a host of tables and flow-charts, making easy synopsis a challenge.
For example, here is what the guidelines Conclusion says:
Through a rigorous process, 4 groups of individuals were identified for whom an extensive body of RCT evidence demonstrated a reduction in CVD events with a good margin of safety from moderate- or high-intensity statin therapy:
4 Statin Benefit Groups:
1. Individuals with clinical CVD
2. Individuals with primary elevations of LDL C ¥190 mg/dL
3. Those 40 to 75 years old with diabetes and LDL C 70 to189 mg/dL without clinical CVD
4. Individuals without clinical CVD or diabetes who are 40 to 75 years of age with LDL C 70
to 189 mg/dL and have an estimated 10-year CVD risk of 7.5% or higher.
Individuals in the last group can be identified by using the Pooled Cohort Equations for CVD risk prediction developed by the Risk Assessment Work Group. Lifestyle counseling should occur at the initial and follow-up visits as the foundation for statin therapy and may improve the overall risk factor profile.
One well-known cardiologist, Dr. Steven Nissen of the Cleveland Clinic, had this perspective, as reported on CNN: This is an enormous shift in policy as it relates to who should be treated for high levels of cholesterol. For many years, the goal was to get the 'bad' cholesterol levels -- or LDL levels -- below 100. Those targets have been completely eliminated in the new guidelines, and the threshold for treatment has been eliminated." The reporter paraphrased him thus: The biggest change from the old guidelines, he says: Ignore the numbers.
ACSH s Dr. Gilbert Ross had this comment: These recommendations are both counter-intuitive and complex, two factors which in and of themselves will impede their progress in being taken up in the community. Doctors and patients have been attuned for decades now to pay careful attention to LDL and HDL levels, and to adjust treatments, generally statin drugs, towards attaining a goal or target level. Now, suddenly, the take-home message is, Treat the whole patient and his or her risk factors, considering cholesterol as one part but not the main target. But many clinicians will be suspicious of the evidence for such a change, and importantly will consider the time it takes to counsel patients on lifestyle factors and accessing the Pooled Cohort Equations for CVD with the patient standing by when they have become accustomed to checking the HDL/LDL levels and writing a prescription for a statin, end of story. I d give this new paradigm a few years and check on follow-up studies before endorsing them.
