Thursday, August 15, 2019

Retrospective #180: The AHA/ACC Cholesterol Guidelines

In late 2013, the American Heart Association and the American College of Cardiology (AHA/ACC) issued a new set of cholesterol guidelines that is proving to be as disruptive as the Affordable Care Act (Obamacare). In fact, it is so much so that Medscape Cardiology issued a Special Report titled, “CV Risk Calculator and Guidelines Controversy.” It has six separate links to “News” and six more to “Experts Weigh In.” That’s way too much information for here.
So, succinctly put, what are the new cholesterol guidelines? And what’s all the stir all about?
The main recommendations are that individuals who fall into any of the following categories should be on a statin:
1.      Those with existing heart disease.
2.      Those with LDL levels above 190mg/dL
3.      Those with diabetes aged 40 to 75 years with LDL between 70-189mg/dL and without existing heart disease.
4.      Those without heart disease or diabetes, with an LDL between 70-189mg/dL and as estimated 10-year heart attack risk of above 7.5%.
The above bullets and the following analysis were provided by Ronesh Sinha, MD, at South Asian Health Solution.
“When comparing the old guidelines to this one, the first 3 categories are essentially unchanged. Most doctors would put heart disease patients, diabetics and those with LDLs above 190 mg/dl on statins. There are some advantages to the newer guidelines:
·         The focus of therapy is on statins, which are the default drug of choice. This is a good thing for those who truly need statins and should hopefully avoid cumulative toxicity from multiple drugs.
·         The concept of treating to a specific LDL target number has been eliminated. This is good since it should reduce unnecessary high dose statin therapy to reach low targets which have not been proven to reduce heart attack risk.
·         These guidelines do a better job of highlighting statin adverse side effects which will hopefully make clinicians think twice before pulling the statin trigger.
·         Greater overall emphasis on heart attack risk rather than a focus on the LDL number which makes more sense.”
Dr. Sinha’s main criticism is of the guideline’s 4th category: individuals who have no risk factors other than a 10-year heart attack risk above 7.5%. This is significantly lower than the prior cutoff of 20% and will result in many more people taking statins. Many more! And that’s actually an understatement. I recently saw an interview of a healthy individual on TV in which the doctor said to the 38-year old male, “In 2 years [when the patient achieved the category #3 threshold age of 40], you’ll be on a statin.” So, I decided to apply the “risk calculator” to myself.
The “risk factors” that are the sole basis of the 10-year heart attack risk are: Sex, Age, Race, Total Cholesterol, HDL-Cholesterol, Systolic Blood Pressure, Treatment for High Blood Pressure, Diabetes, and Smoker. I plugged my data into the new risk calculator and came up with a 10-year risk of atherosclerotic CVD of 28.1% (vs. 7.5%). Wow!
Then, I decided to see what I could do to lower my risk.  Age, sex, race were not things I could change. Neither could I improve my systolic blood pressure (110) or my diabetes (yes), treatment for hypertension (yes) or smoking status (no). And my HDL (85) was already outstanding. So, for me, that left only lowering Total Cholesterol (TC) and, using the Friedewald formula, the calculated LDL value. Quelle surprise! That’s what a statin does. So, I decided to ‘prescribe’ a statin for myself to lower my LDL and thus TC cholesterol by 50mg/dL, easily achieved on a statin. That would lower my LDL to 72, aligned to the goal of 70. Result, my 10-year risk of ASCVD was reduced from 28.1% to 25.3%. Hmmm… That reduction, even while taking a statin, was disappointing, to say the least.
Turns out, the only thing I could do that would lower my 10-year risk factor to 8% (near the 7.5% goal), was to lower my age 15 years. Otherwise, if my doctor followed these new guidelines, I would be on a statin.  No way, Jose! Fortunately, my doctor doesn’t follow the 40-year old rule, but your doctor may. Do you see where I’m going?

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