Guidance on Cholesterol Guideline

The 2013 American College of Cardiology/American Heart Association cholesterol guideline identifies 4 groups of patients (>21 years old) likely to benefit from statin therapy:

1)    Patients with known atherosclerotic cardiovascular disease

2)    Patients with primary elevations of LDL > 190

3)    Diabetic patients aged 40-75

4)    Patients aged 40-75 with estimated 10 year CV risk > 7.5% using a new Pooled Cohort Equation

The guideline recommends high intensity (LDL reduction >50%; e.g. atorvastatin 40-80 mg daily) or moderate intensity (LDL reduction 30-50%; e.g. atorvastatin 10-20 mg daily) statin therapy for all these groups.  Aiming for specific, LDL targets is no longer recommended. Using other, lipid lowering medications is discouraged.

The guideline has generated significant controversy among academics and clinicians.  There is debate about the intensity of statin use, side effects of statins, specific LDL targets, and the new Pooled Cohort Equation to assess 10 year cardiovascular risk. A New England Journal of Medicine article published this week highlights the controversy¹. The article provides a summary of the guideline recommendations.   More importantly, it offers three different, equally rational approaches to managing a particular patient at risk for cardiovascular disease. 

Think of the new guideline as a guide- not a prescription- for managing cardiovascular risk.  Patient preferences matter. Starting statins is a shared decision between physician and patient, a decision that requires a discussion about the risks, harms, and benefits of statins - and what the patient values. 

Finally, forget about statins for a moment.  Don’t let patients forget that exercise, weight reduction, diet, and smoking cessation are even more fundamental to CV risk reduction.     

–Dean Gianakos, MD

1. The Guidelines Battle on Starting Statins. NEJM. 2014; 370(17): 1652-8.