The American College of Cardiology (ACC) and American Heart Association (AHA), in conjunction with the National Heart, Lung, and Blood Institute (NHLBI), have developed and released Guidelines for Cholesterol Control after 9 years of the release of the last version.
And they contain some substantial changes!
Gone are the recommended LDL- and non-HDL–cholesterol targets, specifically those that ask physicians to treat patients with cardiovascular disease to less than 100 mg/dL or the optional goal of less than 70 mg/dL.
According to the expert panel, there is simply no evidence from clinical trials to support treatment to a specific target. As a result, the new guidelines make no recommendations for specific LDL-cholesterol or non-HDL targets for the primary and secondary prevention of atherosclerotic cardiovascular disease.
Instead, the new guidelines identify four groups of patients in whom physicians should focus their efforts to reduce cardiovascular disease events. And in these four patient groups, the new guidelines make recommendations regarding the appropriate “intensity” of statin therapy in order to achieve relative reductions in LDL cholesterol.
The Four Major Statin Groups
The four major patient groups who should be treated with statins were identified on the basis of randomized, controlled clinical trials showing that the benefit of treatment outweighed the risk of adverse events. The four treatment groups include:
1. Individuals with clinical atherosclerotic cardiovascular disease.
2. Individuals with LDL-cholesterol levels >190 mg/dL, such as those with familial hypercholesterolemia.
3. Individuals with diabetes aged 40 to 75 years old with LDL-cholesterol levels between 70 and 189 mg/dL and without evidence of atherosclerotic cardiovascular disease.
4. 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%.
In those with atherosclerotic cardiovascular disease, high-intensity statin therapy—such as rosuvastatin (Crestor, AstraZeneca) 20 to 40 mg or atorvastatin 80 mg—should be used to achieve at least a 50% reduction in LDL cholesterol unless otherwise contraindicated or when statin-associated adverse events are present. In other settings a moderate reduction of LDL-cholesterol may be aimed for.
The guidelines advise not to aim to achieve a target value of LDL-cholesterol in these patients subsets but advice to start statins in moderate or high intensity to achieve significant reductions in LDL cholesterol from their baseline levels.