The cholesterol guideline represents a major change for several reasons. Unlike any previous guidelines in the United States or elsewhere, the cholesterol guideline is truly process oriented and evidence based and summarizes the evidence, based on the amalgamation of data from a review of the world’s literature through July 2013, including individual studies and meta-analyses.
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These guidelines talk about the intensity of lipid-lowering therapy with a statin, mostly about moderate- or high-intensity lipid-lowering therapy. In addition to emphasizing that none of these trials have ever specifically examined the goals for LDL cholesterol, the guidelines state that there are very few data showing significant benefits of non–statin therapies. In the past, clinicians have been pushed toward getting patients to a certain LDL cholesterol goal with treatment, adding other types of cholesterol-lowering therapies, for example, if they cannot get a high-risk patient’s LDL cholesterol down to 70 mg/dL with a statin. But the guidelines emphasize that there is no evidence to support this recommendation and may not be needed once the statin is prescribed (J. Am. Coll. Cardiol. 2013 [doi:10.1016/j.jacc.2013.11.002]).
The risk calculator in the guidelines are going to be more accurate for women and nonwhite populations, which is what the Framingham risk score was lacking, because it was primarily based on white men from Massachusetts. They have incorporated data from other community-based studies with long-term follow-up, to come up with a more accurate risk calculator that is applicable for calculating lifetime risk, and based on data available on other races, particularly African Americans and other nonwhites, and for women. Instead of short-term risk, the new guidelines include the calculation of lifetime risk, and global cardiovascular risk assessment that now include stroke risk, which is currently neglected in cardiovascular risk assessments. Coronary heart disease is the leading cause of death in the United States, but stroke is the fourth leading cause of death. The risk of stroke has frequently been neglected in the assessment of cardiovascular risk assessments and is clearly quite preventable, with similar treatments and interventions that are equally effective, if not more effective. The previous risk calculators did not include stroke risk.
The lifestyle and cholesterol guidelines also emphasize and reemphasize that a prudent diet, regular exercise, and weight loss are critical elements in prevention. And what is also likely to be repeated in hypertension guidelines, they strongly advise reduced sodium intake, which is quite high in Americans, particularly for patients who have hypertension, or are at risk for developing hypertension with borderline hypertension or what has previously been called prehypertension.
They have clearly emphasized that for patients who have low HDL or low triglyceride levels; the results of ACCORD lipid trial or the AIM-HIGH trial did not provide any substantive evidence that once you have reached the LDL goal, there is an additional benefit of adding a fibrate or niacin. This is important, because this has been confusing for practitioners.
Dr. Deedwania is professor of medicine, division of cardiology, University of California, San Francisco. He was not involved in the guidelines. He is an adviser and consultant to Pfizer and Amgen.