November 12, 2018

How to treat high cholesterol, according to new American Heart Association recommendations

Daily Briefing

    New guidelines for treating high cholesterol released by the American Heart Association and the American College of Cardiology on Saturday emphasize a more personalized approach to treatment, updating controversial guidelines released by the organizations in 2013.

    Slides: What's trending in the cardiovascular service line?

    Why the 2013 recommendations were so controversial

    Many providers had expressed concern about the 2013 recommendations, which—in a break from prior practice—did not provide a specific target for LDL, or "bad" cholesterol. Instead, providers were asked to determine a patient's risk by taking into consideration a range of factors.

    Steven Nissen, chair of cardiovascular medicine at the Cleveland Clinic who has prominently criticized the 2013 recommendations, further argued that those recommendations did not adequately account for family risk or provide clear treatment guidelines for people older than 75 or younger than 40.

    Details on the new guidelines

    The new guidelines seek to address many of those concerns. They provide more specific guidelines for when providers should prescribe cholesterol-lowering drugs, taking into account factors such as the patient's family history of heart disease, whether the patient has diabetes, and whether the patient is of an ethnicity considered to be at higher risk.

    For certain high-risk patients whose cholesterol isn't controlled by statins alone, the guidelines also outline when doctors should prescribe two other cholesterol-lowering drugs. According to the recommendations, patients should first try Ezetimibe, a low-cost generic drug that has been shown to reduce LDL cholesterol 20 to 25% lower than statins alone. If that doesn't work, the guidelines recommend PCSK9 inhibitors, which can cost up to $8,000 per year.

    The new guidelines also recommend increased use of imaging scans that can detect calcium deposits in the arteries leading to the heart. These scans are not considered a good tool for the general population, but they can be used to identify patients at an elevated cardiovascular risk, according to the guidelines.

    The recommendations ask providers to assess the effectiveness of a patient's drug regimen within four to 12 weeks.

    New guidelines draw praise from providers

    Nissen said that these new guidelines are "really a reversal of course [from the 2013 guidelines], and I actually think they moved this in the right direction." He added that, when recommending aggressive treatment for patients at the highest risk of heart attacks or stroke, "it helps patients and providers when you give them numbers and targets. Because if you're constantly checking, you keep patients staying focused on compliance, what it takes to stay healthy."

    Francisco Lopez-Jimenez of the Mayo Clinic said the new guidelines are "more pragmatic" and "represent significant positive steps in the way we treat cholesterol, and the way we will assess patients' cardiovascular risk." He added, however, that whether high-risk patients will adhere to recommended medication regimens "is the elephant in the room."

    Harlan Krumholz, a cardiologist and health care researcher at Yale University, said the guidelines provide physicians with more talking points and tools for managing high cholesterol. "I think it's more important to be having discussions with patients about what they want to achieve," he said. "Guidelines can be important in telling people what experts' ideas are. But it's not coming down from the mountain" (McKay, Wall Street Journal, 11/10; Healy, "Science Now," Los Angeles Times, 11/10; Ravitz, CNN, 11/11).

    What's trending in cardiovascular services?

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