Wider Use of Cholesterol Drugs Recommended

Researchers at the American Heart Association and the American College of Cardiology, in collaboration with the National Heart, Lung, and Blood Institute and other specialty societies, published four joint clinical practice guidelines focused on the assessment of cardiovascular risk, lifestyle modifications to reduce cardiovascular risk, and management of elevated blood cholesterol and body weight in adults. The guidelines, which are intended for primary healthcare providers, cardiologists, and others working with patients to prevent cardiovascular diseases, are based on scientific evidence from research studies published between 1990 and 2012, and were developed for adults who would benefit from lowering their blood cholesterol and blood pressure.

The guidelines are the first new ones in a decade and call for twice as many Americans – one-third of all adults – to consider taking cholesterol-lowering statin drugs. Although roughly half the cholesterol panel members have financial ties to the cholesterol-lowering drug manufacturers, panel leaders said those members could not vote on the recommendations. Most of the patents on statins have expired and are widely available now in generic versions.

Statins usage

Of the four guidelines, the elevated blood cholesterol management guideline represents a major change in the thinking on cholesterol and statins usage. The guideline recommends statin therapy for individuals at increased atherosclerotic cardiovascular disease (ASCVD) risk who are most likely to experience a net benefit in terms of the potential to reduce ASCVD events and the potential for adverse effects. The emphasis on treating the sickest and those at highest risk of a heart attack or stroke is a noticeable change from the previous emphasis on lowering cholesterol numbers.

For decades, the public has been focused on those cholesterol numbers and getting the values as low as possible. The new guideline still stresses the importance of cholesterol knowledge, but with additional emphasis on the use of statins for primary and secondary prevention of ASCVD in higher risk patients and not automatically triggering statins treatment for a specific blood cholesterol level. As a result, some people may be able to skip taking statins while others would be put on higher doses. The researchers also suggested the use of statins would not only reduce the large burden of disability from nonfatal stroke and nonfatal cardiovascular events, but also reduce increasing health care costs. According to the guideline, there was no evidence to support continued use of specific LDL-C and/or non-high-density lipoprotein cholesterol (non-HDL-C) treatment targets. The guideline also recommends that physicians forgo prescribing drugs other than statins to reduce the risk of heart attacks and strokes.

Adults would be grouped into categories most likely to benefit from statins, namely individuals with (1) heart disease; (2) Type 2 diabetes, aged 40 to 75; (3) a LDL of 190 or higher, and (4) an elevated, estimated risk of heart disease, aged 40 to 75. The grouping would potentially double the number of Americans, currently around 15 million people, who are candidates for lifelong statin therapy.  A reason for the doubling is if the new guidelines were actually followed people without known cardiovascular disease or diabetes would now be considered for statin treatment if their 10-year risk of heart attack or stroke is more than 7.5 percent. Under the old guideline, the threshold for cholesterol-lowering drug therapy was a 10-year risk of 20 percent.

The guideline still stresses the importance of a healthy diet, weight loss, exercise and blood pressure control in addition to the statin treatment. In borderline cases where doctors are not certain whether to write a statin prescription, the new guidelines say they should take into account a patient’s family history of heart disease and stroke and also consider ordering tests that can indicate underlying artery disease.

Lifestyle changes, obesity and risk assessment

The lifestyle management guideline recommends eating a heart-healthy diet that emphasizes fruits, vegetables, and whole grains, while including low-fat dairy products, poultry, fish and nuts, and limiting red meat, sweets and sugar-sweetened beverages. Following this pattern should help people limit their saturated fat, trans fat and sodium to the recommended levels even if they do not count grams. Saturated fat is found mainly in foods derived from animals, such as fatty cuts of meat and poultry with skin, and full-fat dairy products, tropical oils, such as coconut and palm oil, and trans fat contained in products made with partially hydrogenated fat such as many commercially prepared baked and fried foods. To lower blood pressure, the guideline emphasizes the importance of sodium restriction down from the current excessive average in US adults of about 3,600 milligrams (mg)/day to no more than 2,400 mg/day. Further reduction to 1,500 mg/day was desirable since this value was associated with a greater reduction in blood pressure.

The obesity and overweight adult guideline addresses the appropriateness of the current BMI and waist circumference cutpoints used to determine risk in adults across diverse populations; the impact of weight loss on risk factors for cardiovascular disease and Type 2 diabetes; optimal behavioral and dietary intervention strategies; lifestyle treatment approaches, such as community-based programs, for weight loss and weight loss maintenance; and benefits and risks of various bariatric surgical procedures. In tandem, the risk assessment guideline provides doctors with a new formula for estimating a patient’s risk that relies upon many factors besides a high cholesterol level, including age, gender, race and factors such as whether someone smokes.

These guidelines would help healthcare providers decide who should be recommended for weight loss and what health improvements could be expected.