How to make sense of the New Cholesterol Guidelines

Abstract

The recently released guidelines of the American College of Cardiology and the American Heart Association (ACC/AHA) for the management of cholesterol in 2103 differed substantially from the previous National Cholesterol Education Program Adult Treatment Panel III guidelines and the existing guidelines in Europe and Canada. The new guideline focuses on atherosclerotic cardiovascular disease (ASCVD) risk reduction, and there is a major paradigm shift in changing from the recommendation of an LDL cholesterol-target centered treatment to an approach of identifying statin benefit groups. The guideline identifies four high-risk groups with the greatest benefits from statin therapy: namely those individuals with pre-existing ASCVD, those with primarily LDL cholesterol elevations ≥ 190 mg/dL (~ 4.9 mmol/L), those age 45-75 years with diabetes and LDL cholesterol 70-189 mg/dL (~1.8-4.9 mmol/L) without clinical ASCVD, and those age 40-75 years without clinical ASCVD with an LDL cholesterol 70-189 mg/dL (~1.8-4.9 mmol/L) and a 7.5% or greater 10-year ASCVD risk. The recommendation to treat with either moderate or high intensity statin (without any LDL cholesterol targets) is based on the estimated cardiovascular risk of the individual. Global ASCVD risk in primary prevention is determined using the new Pooled Cohort Equations derived from data based on 5 National Heart, Lung, and Blood Institute-sponsored longitudinal population cohorts of African Americans and non-Hispanic white men and women. The new ACC/AHA guideline has generated much controversy and the potential implications of adopting the new ACC/AHA guideline and their limitations will be discussed.