One out of every 3 American adults has high cholesterol, which raises their risk of heart disease – the No. 1 cause of death in the U.S. – and stroke.
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How doctors go about caring for patients with high cholesterol is influenced by a set of guidelines published and updated periodically by the American College of Cardiology and American Heart Association.
New updates just made to those guidelines represent “a significant improvement” over the last updates made to them in 2013, says cardiologist Steven Nissen, MD.
The latest guidelines maintain an emphasis on the importance of a healthy lifestyle – including a nutrient-dense diet and regular exercise – as the first step in preventing heart disease and stroke. They also emphasize that treatment decisions about high cholesterol should be a collaboration between doctors and patients, Dr. Nissen says.
But they also address some concerns that doctors had after the last set of guidelines was published in 2013, as well as some additional improvements.
A flaw in the risk calculator
One of the most-criticized aspects of the 2013 guidelines was the introduction of a “risk calculator” to help physicians assess a person’s 10-year risk of heart disease and whether they should be treated with statin drugs.
Some doctors raised alarm about the calculator, saying it could over- or underestimate a person’s individual risk because it was designed based on population-level data. The calculator didn’t, for example, take into account an individual’s family history, which doctors have long known is an important risk factor for heart disease, Dr. Nissen says.
The new version of the guidelines encourages physicians to base treatment recommendations not just on the calculator but also on factors including family history and whether someone is of high-risk ethnicity.
They also recommend that patients discuss certain health conditions that could affect their risk or treatment with their doctor, such as metabolic syndrome, chronic kidney disease, inflammatory conditions, premature menopause or pre-eclampsia, or high lipid biomarkers.
A focus on reducing LDL target levels
Another notable change, according to Dr. Nissen, is that the new guidelines bring back the notion that lower levels of low-density lipoprotein (LDL) cholesterol are desirable and should be targeted and measured.
LDL is a major cause of coronary artery disease and is the culprit behind most troublesome cholesterol buildup in the arteries. But the 2013 recommendations eliminated target LDL values for patients requiring treatment. They essentially recommended that patients either take statins or not based on that person’s level of risk as determined by the calculator, rather than by LDL levels.
The new guidelines suggest that people with LDL levels above 70 who are at high risk for heart disease should consider cholesterol-lowering therapy.
“They are bringing back these LDL thresholds for treatment,” Dr. Nissen says.
They also recommend monitoring a patient’s LDL values shortly after starting a new treatment, and then periodically thereafter. “I think this is prudent – it lets patients know how they’re doing, it emphasizes compliance and it ensures that people will have lower levels of cholesterol,” Dr. Nissen says.
A roadmap for new medications
Statins remain the primary drug treatment for lowering cholesterol, but since 2013, more studies have shown the safety and efficacy of newer medications.
The updated guidelines recommend the addition of ezetimibe, which is now available as a generic drug, for high-risk patients who haven’t seen their LDL cholesterol drop by at least 50 percent with use of statins alone. If that doesn’t work, they might also try PCSK9 inhibitors.
Regardless of treatment, the guidelines advise periodic lipid testing to see whether the medications are actually reducing LDL levels.
A ‘lifespan’ approach
The new guidelines include recommendations for cholesterol testing for kids as early as 2 years old who have a family history of heart disease or high cholesterol.
“They also acknowledge that treating high-risk patients over 75 and under 40 may be appropriate in some circumstance,” Dr. Nissen says. These age groups had not been addressed in prior recommendations.
Despite all of these improvements, Dr. Nissen maintains that heart disease isn’t all about numbers, and that everyone should have a well-informed discussion with their doctor about their risk.
“What good doctors do is sit down and go over with patients the risks and benefits of treatment,” he says. “Then, together they make a decision on whether the patient should get treatment.”