NEW GUIDELINES FOR
CHOLESTEROL
NEW CHOLESTEROL GUIDELINES 2013
Recently updated guidelines for the treatment of high blood cholesterol
levels is a major update since 2002.
The news media have trumpeted that it will lead doctors to prescribe statins to
millions more people; calling it a tectonic shift in the way doctors will treat high
cholesterol. The new guidelines could double the number of people on statin.
In contrast to older ones, the new guideline has been a subject of controversy.
Nevertheless, these recommendations are likely to have a major effect on the
clinical practice of lipid management.
WHAT IS NEW…?
An approach that disregards target levels and is based only on risk level and
intensity of statin therapy. In essence, it is switch from treating lab tests to treating
patients.
No evidence to support adjusting treatment to achieve specific target levels of LDL-C.
A new risk calculator to identify those with a risk of 7.5% or higher for having a
cardiovascular event in the next 10 years.
The guidelines are the same for women as for men.
WHAT IS ASCVD – ATHEROSCLEROTIC CVD?
The following are the examples of ASCVD
- Acute coronary syndromes
- Stable and unstable angina
- History of MI
- Coronary revascularization
- Stroke or TIA presumed to be from atherosclerotic origin
- Peripheral arterial disease & revascularization
RISK CALCULATOR
This downloadable spreadsheet is a companion tool to the 2013 ACC/AHA Guideline
on the Assessment of Cardiovascular Risk.
The spreadsheet helps us estimate 10-year and lifetime risks for atherosclerotic
cardiovascular disease (ASCVD.
The information required to estimate ASCVD risk includes
- age, sex, race,
- total cholesterol, HDL cholesterol,
- systolic blood pressure, blood pressure lowering medication use,
- diabetes status, and smoking status.
HOW TO CALCULATE RISK
Step 1. Click on this link (or copy paste if link does not work)
http://my.americanheart.org/professional/StatementsGuidelines/PreventionGuidelines/PreventionGuidelines_UCM_457698_SubHomePage.jsp
Step 2.
Click on the tab that says “download CV risk calculator ” on right side (we need MS
office/Excel software on our computer )
Step 3. Once we start filling in the blank in column C (age, sex, race etc..), we will
automatically start seeing colorful bars and calculations; very innovative !
AN EXAMPLE OF ASCVD RISK CALCULATION
NEW GUIDELINE FOR STATIN THERAPY
INTENSITY OF STATIN THERAPY ( HIST & MIST )
KEY FEATURES OF THE NEW GUIDELINES
It identifies 4 subgroups of patients for whom the benefit of statins clearly outweighs
the risk and require high-intensity statin therapy (HIST)




1. Clinically evident atherosclerotic cardiovascular disease,
2. Primary LDL cholesterol levels of at least 190 mg per deciliter,
3. Type 1 or 2 diabetes and LDL level of 70 or higher,
4. 10-year risk of atherosclerotic cardiovascular disease of at least 7.5% and an LDL level of at least 70.
In these patient groups, high-intensity statin therapy (designed to reduce LDL cholesterol levels by ≥50%) is
generally recommended.
MODERATE INTENSITY STATIN THERAPY : MIST
MIST : (aiming for a reduction of 30 to <50% in LDL cholesterol levels) is
recommended for patients who
 cannot tolerate high-intensity treatment or
 patients with diabetes and a 10-year risk of atherosclerotic cardiovascular disease of < 7.5%.
Persons receiving statin therapy should be monitored for muscle and hepatic injury
and for new-onset diabetes.
WHO NOT TO TREAT WITH STATIN
The new guidelines also identifies patients for whom available data do not support
statin therapy and for whom no recommendation is made. These groups are …
1. Age of > 75 years, unless clinical atherosclerotic cardiovascular disease is present;
2. Need for hemodialysis; or
3. New York Heart Association class II, III, or IV heart failure.
The panel found no evidence to support the use of non-statin cholesterol-lowering
drugs, either combined with statin therapy or in statin-intolerant patients.
OTHER FACTORS TO BE CONSIDERED
1.
2.
3.
4.
5.
6.
Primary LDL–C ≥160 mg/dL or other evidence of genetic hyperlipidemias,
Family history of premature ASCVD with onset <55 years of age in a first degree male
relative or <65 years of age in a first degree female relative,
High-sensitivity C-reactive protein >2 mg/L,
CAC score ≥300 Agatston units or ≥75 percentile for age, sex, and ethnicity,
Ankle-brachial index <0.9, or
Elevated lifetime risk of ASCVD.
 CAC Score : The presence of calcification on a coronary artery calcium (CAC) scan
 These patients are likely to need individualized or specialized care
IMPORTANT ROLE OF PROVIDERS
The guidelines are not intended to be a cookbook, one-size-fits-all approach.
Providers are expected to
- Look for secondary causes of hyperlipidemia, to take other individual patient
factors into consideration
- Encourage Lifestyle modification: ( heart healthy diet, regular exercise habits,
avoidance of tobacco products, and maintenance of a healthy weight)
OVERALL HEART HEALTH
In addition to the guidelines on evaluating cholesterol risk, two other sets of
guidelines relating to overall heart health has also been released.
1. Eating a heart-healthy diet, including reducing saturated and trans fats as well as
limiting sodium to 2,400 mg per day -2. Treatment guidelines on managing weight loss in patients.
A. Help create individualized weight loss plans and recommend counseling with a
dietitian or other certified weight loss professional for at least six months.
B. Offer bariatric surgery as a potentially viable option for patients with a BMI over
40, or those with a BMI over 35 and other complicating factors.
INITIATING STATIN THERAPY
MONITORING PATIENTS ON STATINS
1.
2.
3.
4.
Regular assessment of adherence to medication and lifestyle
Re-testing lipid levels at intervals as long as 12 months
Other safety measures as clinically indicated
No routine monitoring of liver function tests unless there are
symptoms suggesting liver toxicity.
..
SECONDARY CAUSES OF HYPERLIPIDEMIA
FINALLY, THE GOOD NEWS
- The new methods of assessing cardiovascular risk includes for the
first time not only the risk for heart attack, but also for stroke…
- Almost all statins are now available as generics including Lipitor.