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Heart groups suggest new approach to managing blood cholesterol

Thursday November 14, 2013
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The American College of Cardiology and the American Heart Association released a new clinical practice guideline for the treatment of blood cholesterol in people at high risk for cardiovascular diseases caused by atherosclerosis.

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 myocardial infarction. 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,” Neil J. Stone, MD, the Bonow professor of medicine at Northwestern University Feinberg School of Medicine in Chicago and chair of the expert panel that wrote the new guideline, said in a news release.

“This guideline represents a departure from previous guidelines because it doesn’t focus on specific target levels of low-density lipoprotein 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 patients who have cardiovascular disease, patients with an LDL level of 190 mg/dL or higher, patients with type 2 diabetes who are between ages 40 and 75, and patients with an estimated 10-year risk of cardiovascular disease of 7.5% or higher (the report includes formulas for calculating 10-year risk).

“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,” Stone said. Physicians might also consider switching some patients to a higher dose of statins to derive greater benefit as a result of the new guideline.

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, 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,” Stone said. “No other cholesterol-lowering drug is as effective as statins.” He added that there is a role for other cholesterol-lowering drugs, such as 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,” Stone said. “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 focusing instead on a healthy lifestyle along with a higher dose of statins, thus eliminating the need for additional medications, can be preferable.

“The focus for years has been on getting the LDL low,” Stone said. “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.

Guidelines (PDF): http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a.full.pdf


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