Tue, Nov-13-18, 11:43
To Good Health!
AHA new Revised Guidelines - 2018
The AHA last revised guidelines in 2013. The new 2018 guidelines released with more inclusion of the CAC score.
Management of blood cholesterol just got personal
by Dr. Bret Scher, MD
MedPageAHA: Revised Lipid Guide Boosts PCSK9s, Coronary Calcium Scans
Don’t look now, but the updated clinical practice cholesterol guidelines from the American College of Cardiology, the American Heart Association and others are getting personal. Although the guidelines still contain their familiar approach — that I consider too aggressive with drug therapy — the latest 2018 version of the guidelines now includes an impressive update to emphasize lifestyle intervention, plus a more individualized approach for risk assessment.
MedPage Today: AHA: Revised Lipid Guide Boosts PCSK9s, Coronary Calcium Scans
Could this be the start of a progressive trend away from shotgun statin prescriptions? I sure hope so.
Prior guidelines emphasized the 10-year ASCVD risk calculator as the main determining factor for statin therapy. In the 2018 update, the guidelines acknowledge that the calculator frequently overestimates the risk in those individuals who are more involved with prevention and screening. (In other words, those patients more interested in and proactive about their health; I find many in the low-carb world fall into this category.)
The ensuing discussion with a healthcare provider should then focus on:
[T]he burden and severity of CVD risk factors, control of those other risk factors, the presence of risk-enhancing conditions, adherence to healthy lifestyle recommendations, the potential for ASCVD risk-reduction benefits from statins and antihypertensive drug therapy, and the potential for adverse effects and drug–drug interactions, as well as patient preferences regarding the use of medications for primary prevention… and the countervailing issues of the desire to avoid “medicalization” of preventable conditions and the burden or disutility of taking daily (or more frequent) medications.
I appreciate the attention the new guidelines bring to the depth of the discussion that should ensue between doctor and patient. Considering the treatment burden is equally as important as the burden of disease, and possibly even more important in patients who have not been diagnosed with heart disease, these individualized discussions about trade-offs are critical to personalized care.
Also worthy of mention is the increased use of coronary artery calcium scores (CAC) to help individualize risk stratification. The updated guidelines specify CAC may be useful for those age 40-75 with an intermediate 10-year calculated risk of 7.5%-20%, who after discussion with their physician are unsure about statin therapy. They specify that a CAC of zero would suggest a much lower risk than that calculated by the ASCVD risk formula, and thus take statins off the table as a beneficial treatment option.
This is huge. I cheered when I read this! I have been critical of prior guidelines that focused on ways to find more people to place on statins. The mention of finding individuals unlikely to benefit from statins is a giant step in the right direction.
The guidelines go even further: they mention that a CAC either over 100 or greater than the 75th percentile for age increases the CVD risk and the likely benefit of a statin. A CAC between 1-99 and less than the 75th percentile does not affect the risk calculation much and it may be worth following the CAC in five years in the absence of drug therapy. I would still argue that a CAC >100 does not automatically equal a statin prescription and we need to interpret it in context, but I greatly appreciate this attempt at a more personalized approach.
The guidelines also go beyond the limited risk factors included in the ASCVD calculator by introducing “risk modifying factors” such as:
Premature family history of CVD
Chronic kidney disease
Chronic inflammatory conditions such as rheumatoid arthritis and psoriasis
Elevated CRP > 2.0 mg/L
Elevated Lp(a) > 50 mg/dL or 125 nmol/L
Elevated triglycerides > 175 mg/dL
Although they use these criteria to define an increased risk, the opposite would likely hold true. An absence of those criteria could define a lower risk situation.
Some changes deserve mention from a controversy standpoint as well. For instance, the new guidelines recommend checking lipid levels as early as two years old in some circumstances. Two!
They also recommend statin therapy for just about everyone with diabetes with no mention of attempting to reverse diabetes before starting a statin, a drug that has been shown to worsen diabetes and insulin resistance. In addition, the new guidelines do not mention the likely discordance between LDL-C and LDL-P in those with diabetes.
Last, the new guidelines define an LDL-C > 190 mg/dL as an absolute indication for statin therapy with a treatment goal of 190 mg/dL is in familial hypercholesterolemia populations (and even then has heterogenous outcomes). There is a clear lack of data supporting that same recommendation for metabolically healthy individuals with no other cardiac risk factors and no other characteristics of familial hypercholesterolemia. This is a clear example of when a guideline turns from “evidence based” to “opinion based.”
In summary, the guideline committee deserves recognition for its emphasis on an individualized care approach, its use of CAC, and its broader description of discussing potential drawbacks of drug treatment. It still combines opinion with evidence and believes all elevated LDL is concerning, but I for one hope it will continue its progression away from generalizations and someday soon see that individual risk variations exist, even at elevated LDL-C levels.
Thanks for reading,
Bret Scher MD FACC
New recommendations aim to cut statins in low-risk primary prevention
CHICAGO -- Updated national lipid guidelines present an algorithm for when to reach for a PCSK9 inhibitor and revise risk assessment in primary prevention.
The PCSK9 inhibitors were recommended by the American Heart Association (AHA) and American College of Cardiology (ACC) as "reasonable" for very high-risk atherosclerotic cardiovascular disease patients with multiple prior major events or a single such event plus multiple high-risk conditions when low-density lipoprotein (LDL) is 70 mg/dL or higher on maximally tolerated statin and ezetimibe (Zetia) therapy.
The class also got "may be considered" status for primary hypercholesterolemia regardless of 10-year atherosclerotic cardiovascular disease risk if LDL starts at 190 mg/dL or greater and doesn't drop below 100 mg/dL on a high-intensity statin plus ezetimibe and remains ≥100 mg/dL and the patient has multiple factors that increase risk.
"Ezetimibe is much less expensive, so we want people to try that first," noted Donald Lloyd-Jones, MD, of Northwestern University and a co-author of the guidelines released here at the AHA meeting and published simultaneously online in Circulation.
Click here for exclusive video comments from study authors and leading cardiologists on the AHA late-breaking trials.
The other big change in the guidelines was in risk assessment for lipid-lowering primary prevention in people without diabetes.
It's the same risk-pooled cohort equations and calculator that were so controversial when released in 2013, "but we use it in a much more sequential way that gets to much better answers," noted Lloyd-Jones in an interview with MedPage Today. "Between the risk-enhancing things and the coronary calcium scanning, we're going to be much smarter about who should and should not be on a statin."
He and his colleagues dug into concerns of overestimation of risk with those tools in a special report published alongside the guidelines in Circulation. They found nuance.
"In the broad clinical population, they actually seem to be well calibrated," he said. "In patients in groups where they are high socioeconomic status or they're very [sic...no idea dropped sentence?]
Thus, the guidelines recommended to personalize the discussion for adults ages 40 to 75 before starting statins for primary prevention, with review of major risk factors including 10-year atherosclerotic cardiovascular disease risk calculation, comorbidities and history that could play a role, potential for adverse effects, costs, and patient preferences and values.
Coronary artery calcium (CAC) scans got a boost from a 2b recommendation to now a 2a endorsement for an intermediate-risk group: adults 40 to 75 years of age without diabetes, with LDL in the 70 to 189 mg/dL range, at a 10-year atherosclerotic cardiovascular disease (ASCVD) risk of 7.5% to 19.9%, if the decision about statin therapy is uncertain.
"If CAC is zero, treatment with statin therapy may be withheld or delayed, except in cigarette smokers, those with diabetes mellitus, and those with a strong family history of premature ASCVD," the document said.
That's actually about half of this large indeterminate group, Lloyd-Jones noted.
While the U.S. Preventive Services Task Force opted earlier this year not to back CAC scans for cardiovascular risk assessment in asymptomatic people due to insufficient evidence supporting a clinical endpoint benefit, the observational evidence was enough for the AHA/ACC. "We know what statins can do for those people in terms of reducing risk," Lloyd-Jones said.
"My personal hope is that that will push payers to start to cover this, because that has been a long time coming."
Additional groups that endorsed the recommendations were the American Association of Cardiovascular and Pulmonary Rehabilitation, American Academy of Physician Assistants, Association of Black Cardiologists, American College of Preventive Medicine, American Diabetes Association, American Geriatrics Society, American Pharmacists Association, American Society for Preventive Cardiology, National Lipid Association, and Preventive Cardiovascular Nurses Association.