Critiques and explanations of new cholesterol guidelines published

Four new articles in Annals of Internal Medicine address the practice implications and controversy surrounding recent cholesterol treatment guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA).

The guidelines were released Nov. 12, 2013, by the Journal of the American College of Cardiology and Circulation and were covered in ACP InternistWeekly on Nov. 19. The Annals responses were published online Jan. 28.

In the first Annalsarticle, members of the panel that wrote the ACC/AHA guidelines provided a synopsis of the key features of the recommendations. They broke the guideline recommendations down into 8 areas: lifestyle, groups shown to benefit from statins, statin safety, decision making, estimation of cardiovascular disease risk, intensity of statin therapy, treatment targets, and monitoring of statin therapy.

An article in the Ideas and Opinions section highlighted some core concepts of the guidelines and discussed controversial aspects. The guidelines significantly changed previous practice by expanding their scope from prevention of coronary heart disease to atherosclerotic cardiovascular disease, including stroke, the authors said. The most controversial aspects were new risk assessment methods (including a calculator for 10-year risk) and discontinuation of treatment to a lipid target. To resolve concerns about these changes, the authors of this article suggested that clinicians could use an expanded definition of intermediate risk (5% to 15%) and refine treatment for patients in this group according to family history and coronary artery calcium score. While risk assessment should be the impetus for treatment, lipid measurements can still “serve as a marker of therapeutic response, promote adherence, motivate lifestyle improvements, and guide discussions about add-on pharmacological therapy,” the authors said.

Another Ideas and Opinions piece praised the guidelines for discontinuing treatment to target but expressed concern about the lowering of risk thresholds for primary prevention. The authors would prefer that pharmacotherapy be initiated in patients whose risk is at least 10% or 15%, according to the new calculator. They recommend that patients in this risk category participate in shared decision making about statin treatment. The authors also disagreed with the guidelines' use of high-intensity statins. The authors proposed starting with moderate doses in most patients and using a shared decision-making approach to increase the dose.

Finally, an editorial analyzed why guidelines, including the ACC/AHA cholesterol recommendations, are controversial. Controversy could be reduced by including more stakeholders during development (such as through a public comment period); basing guidelines on formal, peer-reviewed, publicly available evidence reviews; providing education materials about supporting evidence for physicians and patients; and avoiding creation of a media event around release of a new guideline, the editorialist said.