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New cholesterol guidelines offer a more personalized approach

New cholesterol guidelines recommend a more personalized approach in risk assessments, a returned focus on L...

Posted: Nov 20, 2018 3:22 AM
Updated: Nov 20, 2018 3:22 AM

New cholesterol guidelines recommend a more personalized approach in risk assessments, a returned focus on LDL target levels and new drug options for those at highest risk for cardiovascular disease. The guidelines were announced Saturday during the American Heart Association's annual scientific conference.

The recommendations, set out by the American Heart Association and the American College of Cardiology, also discussed the value of using coronary artery calcium scores for some patients and expanded the age range for treatment.

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"High cholesterol treatment is not one size fits all, and this guideline strongly establishes the importance of personalized care," Dr. Michael Valentine, president of the American College of Cardiology, said in a press release.

"Over the past five years, we've learned even more about new treatment options and which patients may benefit from them," he said. "By providing a treatment roadmap for clinicians, we are giving them the tools to help their patients understand and manage their risk and live longer, healthier lives."

Criticism of previous guidelines

The new recommendations address many of the concerns raised when the guidelines were last updated five years ago.

Those 2013 guidelines were troublesome for a number of reasons, explained Dr. Steven Nissen, chairman of cardiovascular medicine at the Cleveland Clinic: The previous guidelines used a risk calculator that left out crucial components such as family history; they didn't address the issue of people older than 75 or younger than 40; they overhyped the risks many patients faced while lowering the threshold needed to warrant statin drug therapy; and they did away with the use of LDL (bad) cholesterol target levels, which helped patients set meaningful goals.

People with LDL levels of 100 or lower, "tend to have lower rates of heart disease and stroke, supporting a 'lower is better' philosophy," according to a statement from the medical organizations about the new guidelines.

A level of above 160 is considered "very high," according to a release from Johns Hopkins Medicine, which also outlined the new guidelines. For high risk patients, the recommendation is to lower "bad" cholesterol to levels below 70.

If statin therapy fails to lower LDL levels adequately, in patients who've already had a heart attack or stroke, the new guidelines suggest adding other drugs -- ezetimibe, which is available as a generic -- to the regimen. If that combination doesn't work sufficiently for patients who are at a very high risk, a PCSK9 inhibitor can be added.

The new approach encourages increased collaboration between doctors and their patients. Doctors are encouraged to discuss a broad range of factors that may increase risks, such as family history and ethnicity, as well as other conditions including metabolic syndrome, premature menopause and chronic kidney disease.

Impact of high cholesterol on all age groups

Doctors are also being urged to look at the lifetime of patients and how high cholesterol takes a toll. Children born to especially high-risk families can be tested when they are as young as 2. For most children, though, the recommendation is to have an initial test between ages 9 and 11, and then a follow-up test between the ages of 17 and 21.

And just as cholesterol levels in younger people shouldn't be ignored, the same goes for those over 75, the new recommendations say.

"They now acknowledge that it might be appropriate to treat older people," something they didn't do in 2013, said Nissen, who was highly critical of the last round of guidelines. "Today's 75-year-old can live a long time."

All of these developments are good signs, "a step forward," Nissen said. "It took five years to fix the problems with the last set of guidelines, but I'm glad they've been addressed."

Nissen offered just one criticism of the new recommendations: the suggestion that coronary artery calcium scores be used to help determine the need for cholesterol-lowering treatments in patients for whom the need isn't clear. This score shows plaque buildup in arteries and is determined through a CT scan, he said.

At the Cleveland Clinic where he works, Nissen said a scan for a coronary artery calcium score costs less than $500, but the more thorough scan that includes angiography exceeds $1,000.

"You're radiating somebody in order to decide whether to use a drug that costs as little as $3 a month, and you're spending a lot of money to do it," he said. "I just don't think it's prudent."

There are other cardiologists, however, who argue that the cost for a coronary artery calcium scan can be nominal.

Other than this area of dispute, Nissen is pleased with the updated recommendations. "The big picture is this is a reasonable set of guidelines," he said.

Heart disease is the leading cause of death in the US, according to the US Centers for Disease Control and Prevention. Cardiovascular disease, which includes conditions that cause heart attacks and strokes, account for more than 836,000 deaths a year, according to the American Heart Association and the American Stroke Association.

"Having high cholesterol at any age increases that risk significantly," Dr. Ivor Benjamin, president of the American Heart Association, said in a written statement. "That's why it's so important that even at a young age, people follow a heart-healthy lifestyle and understand and maintain healthy cholesterol levels."

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