Hear Ye Hear Ye! Are the New Cholesterol Recommendations the Game-Changer of 2013?

Dr. Sharon Orrange
Dr. Orrange is an Associate Professor of Clinical Medicine in the Division of Geriatric, Hospitalist and General Internal Medicine at the Keck School of Medicine of USC.
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For the first time in a decade, the American College of Cardiology (ACC) and the American Heart Association (AHA) have made new recommendations for who we treat with statins for high cholesterol and toward what goal. The new guidelines are different. Here is what you need to know:

 •  Gone are the recommended LDL cholesterol targets, specifically those that ask physicians to treat patients with cardiovascular disease to less than 100 or the optional goal of less than 70. There is now NO target LDL number, rather a reduction.

 •  Instead, the new guidelines lay out four groups of patients who should be treated with statin drugs to reduce cardiovascular disease events.

 •  Sort of bad news for non-statin cholesterol drugs. Poor Zetia. This panel pointed out that the use of of LDL-cholesterol targets (lowering to 70) results in overtreatment of patients with non-statin drugs. This includes Zetia (or combinations like Vytorin), niacin or fibrates (fenofibrate or Tricor). Turns out these meds have not been shown to reduce the risk of cardiovascular disease.

 •  So do I need my LDL checked over and over again? Well it is a good marker of compliance (whether or not you are taking your meds) so we will still want to check on it. Maybe not as often.

The FAB FOUR. The four treatment groups include:
 •  Individuals with clinical atherosclerotic cardiovascular disease (known as heart disease).

 •  Individuals with LDL-cholesterol levels >190, such as those with familial hypercholesterolemia.

 •  Individuals with diabetes aged 40 to 75 years old with LDL-cholesterol levels between 70 and 189 and without evidence of atherosclerotic cardiovascular disease. This is basically most diabetics.

 •  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% (as calculated in easy to obtain risk calculators, online or iphone app).

So what is our goal?
 •  You no longer chase a number (an LDL goal). In those with atherosclerotic cardiovascular disease, high-intensity statin therapy (such as atorvastatin 80 mg a day or Crestor 20 mg to 40 mg) should be used to achieve at least a 50% reduction in LDL cholesterol.

 •  Same goal for folks with LDL > 190: you want to achieve at least a 50% reduction in LDL-cholesterol levels.

 •  For those with diabetes aged 40 to 75 years of age, a moderate-intensity statin, a drug that lowers LDL cholesterol 30% to 49%, should be used.

 •  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, treatment with a moderate- or high-intensity statin is recommended.

What score do i use to see if I’m at 7.5% or not? What’s weird is this risk score does not take into account family history of premature cardiovascular disease, triglycerides, waist circumference, body-mass index, lifestyle habits, and smoking history. It is age, cholesterol, blood pressure, age and whether or not you take a blood pressure medication.

Get this. Even if you have an LDL of 70-100 but your risk score exceeds 7.5% per these new guidelines you should be treated. This will bother some people.

Statins everywhere? Yes, 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. At least most statins are generic, and cheap. This is a gift for Crestor, and a blow to medications like Zetia that play no role in these guidelines at all.

Upsides! Statins have an impact on death and illness from heart disease. They are generally very safe.

So there you have it.


Dr O.

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