CHOLESTEROL TREATMENT GUIDELINES: Latest Info

AHA vs. USPSTF

Both the American Heart Association (AHA) and the United States Preventive Services Task Force (USPSTF) issue guidelines and recommendations for the treatment of elevated cholesterol levels. The science behind the treatment of cholesterol has become so complex and the recommendations so extensive that I decided to see what was new, and what differs between the two organizations. There are so many subcategories, qualifications, and exceptions that one has to sit down and make a chart of the various criteria to get a clear understanding of what to do. Each scenario differs.

The guidelines are recommendations based on five major factors.

Age of the patient

Presence of Arteriosclerotic Cardiovascular Disease (ASCVD)

Calculation of 10-year risk of ASCVD

Diabetes mellitus

LDL Cholesterol levels

Explanation of the details of each:

AGE criteria are separated into two groups:

Age 40-75

Over 75

ASCVD criteria include heart attack, stroke, carotid or lower extremity arterial blockages. High blood pressure and cigarette smoking are included as major contributors to ASCVD.

Calculation of 10-year risk of ASCVD is done by entering personal data into a table that

determines percent risk. Age, blood pressure, Total Cholesterol, HDL Cholesterol, on BP

meds (Y/N), cigarette smoking (Y/N), and Diabetes present (Y/N) are entered into a formula

that calculates the 10-year risk.

Diabetes Mellitus present or not present is a major risk factor for ASCVD and important in Cholesterol treatment. Diabetics simply have worse arteriosclerosis than non-diabetics.

LDL (Bad) Cholesterol levels are used to determine need for cholesterol lowering therapy.

Normal LDL should be less than 130 mg/dL

Treatments Recommended:

Statin drug therapy:

Low intensity therapy—simvastatin 10 mg, or pravastatin 10-20 mg, lovastatin 20 mg, fluvastatin 20-40 mg

Moderate intensity therapy—Lipitor 10-20 mg, Crestor 5-10 mg, Zocor 20-40 mg

Others-pravastatin 40-80 mg, lovastatin 40-80 mg, fluvastatin 80 mg

High intensity therapy—Lipitor 40-80 mg, Crestor 20-40 mg

Ezetimibe (Zetia)—added to statin

PCSK-9 inhibitors—Repatha, Praluent-new, very expensive, injectable drugs

Now it gets complicated!

The forty-seven (47) members of the task force/committee that determines these guidelines and recommendations tried to be detailed and thorough in establishing criteria and taking into account every possible scenario that it becomes confusing and hard to follow. There are so many caveats and subclassifications that qualify each category, it’s befuddling. But I’ll try to summarize this as clearly as possible.

Recommendations:

Regardless of age, patients with Diabetes and ASCVD disease are the highest risk for further events (stroke, heart attack, etc.) and their LDL Cholesterol should be treated with whatever is necessary (statin, Zetia, PCSK-9’s) to a level less than 70mg/dL or 50% of their pre-treatment level.

Regardless of age, patients with severe primary hypercholesterolemia (LDL Cholesterol greater than 190 mg/dL) should be treated with whatever is necessary to a level of 100 mg/dL or less. If they also have risk factors for ASCVD, their LDL Cholesterol should be treated to a level less than 70 mg/dL.

Patients age 40-75 with Diabetes should be treated to an LDL Cholesterol level of 70 mg/dL or less. Moderate-intensity therapy is recommended.

Patients age 40-75 without Diabetes, with an LDL Cholesterol above 70 mg/dL, and a 10-year ASCVD risk above 7.5% should start moderate-intensity statin therapy.

Patients age 40-75 without Diabetes, with a 10-year ASCVD risk of 7.5-20%, and risk-enhancing factors (see below) should start moderate intensity statin therapy.

Risk-enhancing factors include family history of premature ASCVD, LDL level above 160 mg/dL, metabolic syndrome (diabetes, high cholesterol/triglyceride, high BP), chronic kidney disease, history of preeclampsia, premature menopause, chronic inflammatory disorders, and abnormal hs-CRP (a marker for vascular disease).

Patients age 40-75 without Diabetes, with an LDL Cholesterol above 70 mg/dL, and a 10-year ASCVD risk of 7.5-20% should have a Coronary Calcium Score to determine therapy.

Coronary Calcium scores warrant the following therapies:

A level Above 100 Agatston units use statin therapy

A level 1-100 units use statin therapy in patients over age 55

A level of Zero units use statin therapy if the patient is a smoker, diabetic, or has a family

history of premature ASCVD

Patients age 40-75 being evaluated for prevention of ASCVD should have a discussion about risk factors before starting statin therapy.

Patients Age 75 and older with LDL Cholesterol of 70 to 189 mg/dL should have moderate intensity statin therapy. A Coronary Calcium Score is recommended to avoid statin therapy if the score is zero. If the patient has declined physically or cognitively and has a reduced life expectancy, statin therapy may be stopped.

All adult patients are encouraged to practice heart-healthy lifestyle habits to reduce the development of risk factors. This is the foundation of ASCVD preventive therapy.

I said it was complicated, didn’t I.

The USPSTF recommendations differ only in that their 10-year ASCVD risk threshold is 10% or above. Their emphasis is more about guidelines for screenings. They do, however, admit evidence is strong (A) for the value of testing for Total Cholesterol, HDL and LDL Cholesterols.

Dr. G’s Opinion: The National Cholesterol Education Program, NCEP, and AHA, have muddied the water. The complexity of these recommendations is so confusing one needs a detailed chart to know what to do. I think a physician should NEVER HESITATE to prescribe statin therapy unless there is a very good reason not to. Statins have reduced the frequency of heart attacks and sudden death by a significant amount (28%). I can’t remember the last time I heard of someone “dropping dead.” Patients still get coronary disease, but aggressive interventions (angioplasties, stents, CABG) have prevented disabling symptoms and death. Patients with chest pain are not just prescribed nitroglycerin and told to see what happens. Risk factors are identified and treated and chest pain is investigated thoroughly.

The significant risk imposed by cigarette smoking is well-known and the public has recognized the risk and responded by stopping. How many of your friends still smoke?

It’s academically nice to take all of the pertinent risks and scenarios into consideration. But when it’s common knowledge that arteriosclerotic plaques contain cholesterol, what’s there to debate. Statins, like fluoride, should be in the water. They save lives. Statins have side effects, sure. What drug doesn’t? But I saw very few patients who could not tolerate statin therapy, and I was never reluctant to prescribe it. Treating patients to the goal LDL level was a challenge I welcomed. I knew I was doing a good thing for patients. I think time (30+ years) has proven the value of statins, and having these overly complicated guidelines, disrupts one’s ease of decision-making. The AHA means well, but statin-deniers have had a loud and too-influential voice, it seems. Take your statins and thank the scientists who discovered them.

References: Grundy SM, Stone NJ, et al. 2018 “Guideline on the Management of Blood Cholesterol,” Circulation 10 Nov 2018.

AAFP.org/news/health-of-the-public/ahacholguidln.html

drugs.com/drug-class/pcsk9-inhibitors.html

Imperial College of London. “Statins reduce deaths from coronary heart disease by 28% in men, according the longest ever study.” Science Daily, 6 Sep 2017.