It's been more than a decade since the Adult Treatment Panel (ATP-III) issued the third report for the detection, evaluation and treatment of elevated cholesterol. On November 11, 2013, new guidelines replaced the long awaited ATP-IV were released by the American College of Cardiology (ACC) and American Heart Association (AHA), developed in conjunction with the National Heart, Lung, and Blood Institute (NHLBI) [click here for the full report].
At Joslin, we are led by an internationally recognized lipid expert Dr. Om Ganda, who leads the Lipid Clinic. We have conferred with Dr. Ganda and provide summarized key information and its implications for those with diabetes and those at risk. Conceptually there is a move away from a specific LDL values and instead focuses on statin intensity and a de-emphasis for the use of non-stain drugs and non-HDK cholesterol levels. Recent concerns surrounding a new risk calculator to identify those at 7.5% CVD risk in 10 years have been voiced. The risk calculator appears to greatly overestimate risk. Joslin will continue to investigate the ongoing debate in regards to the risk calculator. A new risk calculator to identify those at 7.5% CVD risk in 10 years is the litmus for statin prescriptions.
The guidelines contain the following key points:
1. All patients ( ≥ 21 years of age) with any form of CVD (not only CHD), or LDL-C ≥ 190 mg/dl:
a. Treat with high dose statins
i. e.g.: Atorvastatin 40-80 mg or Rosuvastatin 20-40 mg with the aim to reduce LDL-C by >50 %
2. All patients with diabetes (age 40-75 years) with LDL-C 70-189 mg/dl, without any evidence of CVD should receive statin therapy as follows:
a. Moderate dose statin
i. e.g. Atorvastatin 10-20mg, Rosuvastatin 5-10 mg, Pravastatin 40-80 mg, Simvastatin 20-40 mg, etc, with the aim to reduce LDL-C by 30-50 %.
1. However, consider high dose statin as above if 10-yr risk by new risk calculator >7.5 %.
b. This will translate to many patients with diabetes + additional risk factors
3. If using high dose and moderate dose statins as described above, a specific target of LDL-C goal (< 70 or <100) is not recommended.
As before, all patients must receive intensive lifestyle management.
The published recommendations leave some areas of uncertainty:
Pros, Cons, Caveats, and Concerns:
- The good news is that this algorithm may help reduce some under-treatment and some overtreatment of patients with CVD with evidence-based, proven therapy. However, for primary prevention, these guidelines may lead to some overtreatment.
- In our patients with diabetes for primary prevention (in the suggested age range of 40-75) risk calculations may not be necessary if they have additional risk factors due to the 10-year risk in most will be >7.5 %. The only caveat is some type 1 patients without hypertension or nephropathy, where such calculation may help decision-making. There are likely other factors that determine CVD complications in type 1 patients (e.g. functional properties of HDL).
- One major concern is that adherence improves when patients know their response to treatment (i.e. the LDL-C number; even if we look for a % reduction, rather than a specific target level).
- It is not clear why patients with LDL in 70-100 at baseline need the suggested statin regimen to reduce LDL-C by up to 50 %, which may result in LDL-C down to ~35-50 mg/dl unless they have multiple risk factors. They do advise backing off the dose if LDL-C falls to < 40.
- Curiously, the entity of hypertriglyceridemia receives short shrift in these guidelines. The emphasis is indirect by measuring total cholesterol and HDL-C. Non-HDL-C and/or Apo-B goals are known to enhance risk assessment in such patients due to LDL compositional changes. We, like many others, have been doing routine Apo-B levels at Joslin.
- “Statin- Intolerant” patients: These guidelines appropriately remind folks to try various statins before calling it quits, a frequent practice by PCPs after trying 1 or 2 statins. However, there are a substantial number of patients unable to escalate statin dosage to achieve goals, and there will be even more such patients if they have to achieve >50 % reduction as now advocated.
As always, the Joslin Clinical Practice Guideline Committee will conduct a thorough analysis of the literature and soon update its recommendations considering this new report.
Page last updated: May 21, 2019