Treating Heart Disease: Part 1 Cholesterol

The American College of Cardiology and the American Heart Association published early online 4 joint guidelines on treating & preventing heart disease.  The article that got the biggest play changes the rules when it comes to treating high cholesterol.  Up until yesterday, we used the Framingham risk calculator to determine heart disease risk over the next 10 years and thus LDL goals.  As of today, we are now to consider the use of statins (non-statin drugs did not demonstrate enough clinical outcome benefit to warrant their potential risk) in the following 4 high risk groups:

1) those w/clinical heart disease
2) those w/LDL >190mg/dL
3) those diabetics 40-75yo w/LDL 70-189mg/dL w/o clinical heart disease
4) those w/o clinical heart disease or diabetes but w/LDL 70-189mg/dL plus estimated heart disease risk >7.5%

Of course I type heart disease but the study refers to atherosclerotic cardiovascular disease or ASCVD which clinically includes those w/acute coronary syndromes, history of heart attack, (un)stable angina, coronary or other arterial revascularization, stroke, transient ischemic attack (TIA), or peripheral arterial disease.  Those in groups 1 or 2 don't need to calculate their 10 year risk using the new Pooled Cohort Equations, while those in groups 3 & 4 will use said results to guide the intensity of therapy.

Speaking of intensity of therapy, we no longer have LDL targets.  In other words, I don't have to discuss "good enough" results vs optimal goals.  Instead, we are to offer either moderate intensity or high intensity LDL lowering therapy.  The former is used in appropriate age diabetics w/10yr risk <7.5% or in those who cannot tolerate high intensity therapy.  Just about everyone else in the above 4 groups gets high intensity therapy.  The former aims to lower LDL by 30-50% while the latter aims to lower LDL by >50%.  

Obviously I'm not about to summarize an 85 page guideline in a few simple paragraphs but it's interesting to note that non-statin options were not pushed to assist in achieving LDL goals as there was no outcome benefit from non-statin drugs.  So if you thought you'd heard enough about statins, you ain't heard nothing yet!

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