ACC/AHA new cholesterol management guidelines: what's a doc to do?

to periodically measure lipid levels as this is a strong patient motivator. The new guidelines outline four patient groups targeted for therapy and fortunately three of these are not too different from previous recommendations. Patients with known coronary or cardiovascular disease (prior MI, angina, CABG, stents, stroke, TIA, PAD) should be on statin therapy. In addition, the guidelines include patients with diabetes who many of us have already been treating with statins. The third group are the very rare patients with an LDL >190mg% who are likely to have familial hyperlipidemia and significant family history and where the rationale for treating these patients with statins is more obvious. So far, no big change. The target group that will present the most difficult choices, especially for primary care physicians, are those healthy patients, between the ages of 40 and 75 years with minimal risk factors and LDLs of 70 to 190mg%. For these patients, the new guidelines provide a “Risk Calculator” which includes 8 elements (age, gender, systolic BP, total cholesterol, HDL, DM, treatment for HTN, and smoking status). Noticeably absent from the Calculator elements are a family history of premature cardiovascular disease and an assessment of obesity, such as waist circumference or body mass index (BMI), which are important elements in many risk assessments. That aside, the new guidelines recommend that anyone with a calculated 10-year risk of CV events >7.5% should receive statin therapy. This is where the new guidelines are much more controversial, especially for woman and non-Caucasians, where there is not a lot of data and where the Calculator may significantly overestimate risk and lead to overtreatment. In fact, the Calculator is really only designed to assess risk in the 20to 59-year-old age group. Age and male gender are strong predictors of cardiovascular events, so if you are a 60-year-old male your 10-year risk is already >7.5%! There has been so much controversy and criticism surrounding the Risk Calculator already, that the guideline authors have stepped back and recommended that it may be best used to start the discussion about an individual’s risk and benefits of statin therapy. So you may not want to rush out and buy this App (although I am sure it will be made available for free). Still, it is this fourth group of healthy patients where the current guidelines represent a major departure from prior treatment algorithms for primary prevention. And if these guidelines are applied rigorously, an enormous number of new and previously untreated patients would be started on statin therapy. Many have argued that the data to Le t m e s t at e at t h e outset that I am not a lipidologist, although I have had the opportunity to work with some renowned lipid experts (notab ly, Drs . Pau l Thompson, Peter Herbert and Dick Carleton) over the years and they have taught me a lot. As a clinical cardiologist I have been struggling with how to incorporate the new American College of Cardiology (ACC) and American Heart Association (AHA) guidelines on cholesterol management into my practice. And I have been besieged these past few weeks by my non-cardiology physician and other healthcare professional colleagues, asking whether or not they or their wives should be on a statin. So there is a lot of confusion even among this ultrainformed segment of the population. There is a lot that I like about the new guidelines. They are oriented more towards healthy lifestyle choices rather than a simple LDL target to reduce cardiovascular risk. Lower may not be better (ie, LDL levels), at least not as a focus of therapy. And with that, they have moved us away from complex cholesterol subfractions (apoLa) and adjunctive lipid lowering medications (niacin, ezetimide, fenofibrates, etc.) which have not been shown to improve clinical outcomes even though they may lower the LDL further. I will, however, continue