New Cholesterol Guidelines Released by American Heart Association

2013-11-29 15:21:26

The American Heart Association recently released its updated 2013 guidelines on management of cholesterol levels. The new guideline identifies four groups that are targeted for risk reduction of atherosclerotic cardiovascular disease (ASCVD) through use of cholesterol lowering medications. Two large categories of ASCVD are heart disease and stroke. This new guideline recommends that statin medications may be beneficial for lowering disease risk in individuals with 1) established ASCVD such as angina, history of a heart attack, stroke, etc; 2) otherwise healthy individuals with LDL cholesterol levels above 190 mg/dL, or 4.9 mmol/L in Canadian units; 3) patients with diabetes aged 40 to 75 years who have LDL–cholesterol between 70 to 189 mg/dL (1.8- 4.9 mmol/L, Canadian units) and without clinical ASCVD, or 4) otherwise healthy individuals without established ASCVD or diabetes who have LDL–C between 70 to189 mg/dL (1.8- 4.9 mmol/L, Canadian units) and estimated 10-year ASCVD risk >7.5% (Framingham risk score). The Framingham risk score is a well-recognized scoring system used to estimate an individual’s risk of developing heart disease within the next 10 years, based on demographic data such as age and sex, as well as the presence of risk factors such as being a smoker, having diabetes, blood pressure, and blood cholesterol.

The most surprising of these four groups is the last. The benefit of statins for patients with established disease such as a previous heart attack is relatively uncontested. However, the new guidelines suggest that anyone with modestly elevated risk of cardiovascular disease should be on medication. As an example, using this model, a man with no history of disease but over the age of 40 and “normal” cholesterol (total cholesterol 5.2 mmol/L and good cholesterol, HDL 1.0 mmol/L) and borderline blood pressure 130/80, would be considered to have 7.9% risk, and as such would be recommended cholesterol lowering medication .⁽²⁾

There are some recognized side effects of statin therapy, including muscle damage and pain, liver toxicity, as well as increases in blood glucose levels and possibly increased risk of developing diabetes .⁽¹⁾ The guideline does recommend that all patients on statin therapy should be asked at each visit, both before and after initiation of statin therapy, about muscle symptoms such as muscle weakness or fatigue, aching, pain, tenderness, cramps, or stiffness. In addition, all patients should be screened for onset of new diabetes while on therapy, and have liver enzyme levels checked regularly.

The guideline also stated that “All individuals receiving statins should be counseled on healthy lifestyle habits” .⁽¹⁾ The guideline emphasized that “lifestyle modification (i.e., adhering to a heart healthy diet, regular exercise habits, avoidance of tobacco products, and maintenance of a healthy weight) remains a critical component of health promotion and ASCVD risk reduction, both prior to and in concert with the use of cholesterol lowering drug therapies.” Authors referred to the 2010 guidelines on lifestyle modification, which we will examine next…