They are out; they were years in the making and now they are here- the new cholesterol guidelines- a joint effort by the American College of Cardiology (ACC) and the American Heart Association (AHA). The report is dense, running to more than 80 pages of instructions and recommendations for how medical professionals should treat those at risk of cardiovascular disease, but its overwhelming consensus is that more Americans need additional treatment.
The big change from the Adult Treatment Panel III, the last set of treatment guidelines issued more than 10 years ago, is a philosophical one, based on the scientific evidence. Instead of trying to lower low-density lipoprotein (LDL- often called the bad cholesterol) levels to specific targets as the last three sets of guidelines did; these recommendations categorize whom to treat and how to treat them based on their level of risk and the power of the statin drugs needed to get the job done. Where the benefit to using these drugs is greater than the side effects of long-term drug therapy, the guidelines favor the drugs.
The report identifies four categories of people at risk for CAD that health care providers should focus their attention on:
- 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 percent.
Those in group 1 and 2 should be treated with high dose statins, such as Atorvastatin or Rosuvast. The goal is to reduce LDL cholesterol by 50 percent.
People in group 3 should be prescribed the same drugs, but at lower doses. In this case, health care provider should aim to lower LDL- cholesterol by 30 percent to 50 percent.
The other major change in the guidelines is the recommendation to use an on-line calculator that estimates an individual’s 10-year risk of having an initial cardiovascular event such as a stroke or heart attack. However, many health professionals have some questions about the calculator’s validity. If you use the calculator talk with your health care provider about the results.
If you are over 40 and have diabetes it is very likely that your LDL cholesterol is greater than 70mg/dl .Add this to the number of people with diabetes who are under 40, but have significantly elevated LDL levels and you begin to see the magnitude of the problem. Since most people are diagnosed with type 2 diabetes when they are over 40, and people with type 2 diabetes represent over 90 percent of the population with diabetes, it isn’t difficult to see that if you are an adult and have type 2 diabetes you are probably going to be taking a statin, if not now, in the near future and for a very long time.
While the report highlights the benefits of statin therapy, some other drugs used to treat high cholesterol levels didn’t fare as well. Although Zetia ®(ezetimibe) and Lopid® (gemfibrozil) lower cholesterol, there isn’t data available to prove they lower the risk of CAD.
Robert Gabbay, MD, Chief Medical Officer and Senior Vice President at Joslin, says, “It is unclear if we will be putting more of our patients on statins.” Overall, statins are safe drugs, many people who can’t tolerate one statin, do fine on another. It is important that patients try a few, before giving up on the drugs.”
As in previous versions of the guidelines, lifestyle modifications remain a core component of risk reduction for CAD and should be part of any treatment program.
“Of course treatment decisions still need to be made on an individual basis, says Dr. Gabbay, for example some patients with an LDL of 70mg/dl to 100mg/dl at baseline probably don’t need a 50 percent reduction in LDL which could drive the LDL under 40mg/dl. “
If you have any questions about your risk for CAD or your current medication therapy, call your health care provider.