August 18th, 2014
Advice on Implementing the New Cholesterol Guidelines
Sidney C. Smith, MD
CardioExchange’s Harlan M. Krumholz interviews Sidney C. Smith, coauthor of a new article, published in JACC, that reviews the major findings and recommendations of the 2013 cholesterol guidelines, as well as the recommendations’ implications for risk assessment, LDL lowering, and statin use.
Krumholz: How have the new guidelines changed your practice?
Smith: The new focus on statins, based on their proven clinical outcomes for 4 easily identifiable patient groups, has simplified my practice. I no longer add medicines that may favorably lower LDL cholesterol but have no proven clinical benefit solely to achieve LDL cholesterol targets. My use of lipid-lowering therapies other than statins is now reserved for patients such as those who have familial hypercholesterolemia or are unable to take statins. This makes it easier for my patients and me.
Krumholz: When you start patients on a statin, do you monitor their LDL levels? If so, how often?
Smith: I order a lipid panel, as recommended by the 2013 guidelines, prior to starting statin therapy, then a second panel 4 to 12 weeks later to assess response and confirm adherence. If the LDL level is <40 mg/dL on two successive samples, I consider reducing the statin dose. Afterward, I generally obtain a lipid panel on a yearly basis to assess adherence to therapy and diet, or as otherwise clinically indicated.
Krumholz: What are the two most important things people should learn from your article?
Smith: Physicians should learn the 4 clinical groups with known benefits from statins and the recommended statin dose, high or moderate. In addition, they should access the new risk estimator, to use in talking with patients about statin indications and lifestyle modifications in primary prevention. It is important to emphasize that the new risk estimator also includes stroke and that it has been expanded to include data on African American men and women, a growing segment of our population. Neither stroke as an outcome nor information on African Americans was part of the previous risk-detection approach.
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“I no longer add medicines that may favorably lower LDL cholesterol but have no proven clinical benefit solely to achieve LDL cholesterol targets.” Why were they used before?
“If the LDL level is <40 mg/dL" How was 40 picked? Even 60 or 70 seems low when the person is otherwise healthy and just at say, 8% risk of ASCVD over the next 10 years.
The new risk estimator does not include exercise. For my patients who get an hour a day of vigorous exercise 3-4 days a week, should I consider them to have some percent lower risk? maybe 30% lower?
I am not sure of the significance of age 75 . Do they recommend that anyone over 75 automatically go on statins as being at high risk of ASCVD? or do they withhold recommendations because we do not have adequate evidence for that age group?