Lipid recommendations fill cholesterol guidelines’ black holes
The National Lipid Association (NLA) published recommendations that are designed to help fill the gaps in the 2013 cholesterol guidelines jointly released by two cardiology associations. The report aligns with some aspects of the guidelines but diverges on cholesterol targets.
“There are some very excellent parts to the new guidelines, for example, the four groups of patients who benefit from statins,” Terry A. Jacobson, MD, NLA president and a professor at Emory University School of Medicine in Atlanta, told Cardiovascular Business. But the NLA also identified limitations and a shortfall in information. “In many cases there was no guidance given. Clinicians who see patients in real time need help.”
In late 2013 the American Heart Association (AHA) and the American College of Cardiology (ACC) published guidelines on the management of patients with atherosclerotic cardiovascular disease that raised a ruckus among some cardiologists, primary care physicians and other specialists. The recommendations adhered to evidence from randomized clinical trials; as a result, they did not include some patient populations seen in practice.
The guidelines also veered away from the use of targets for low-density lipoprotein (LDL) cholesterol based on what the expert panel identified as a lack of evidence of clinical benefit. The unveiling of a risk estimator that critics said under– and overestimated risk was another lightening rod issue.
The NLA took a patient-centric and more individualized approach to the management of dyslipidemia, said Jacobson, who was a co-author of recommendations published in the September-October issue of the Journal of Clinical Lipidology. With that focus, the authors reiterated the benefit of setting cholesterol targets, which advocates argue motivate patients and allow physicians to monitor adherence.
“The cholesterol campaign over the years has been one of our most successful campaigns in reducing heart disease in this country,” he pointed out. The lipid community sees little value in discarding an impactful strategy that patients have embraced. They are concerned that a de-emphasis in LDL cholesterol and its monitoring could reverse the gains made.
“Patients need tools. Clinicians need tools to motivate patients to diet and exercise,” he said, adding that their first strategy is behavior modification. “Removing a tool by saying we couldn’t find evidence for or against was premature and I think there will be unfortunate consequences.”
Jacobson said that one such consequence is a move to eliminate LDL cholesterol goals by some organizations in performance metrics, with the downstream possibility that payers will follow by limiting the frequency of reimbursable testing.
The NLA’s recommendations offer guidance on the elderly and younger patients, two groups who fell outside clinical trial data that informed the AHA/ACC recommendations. While many recommendations take aim at LDL cholesterol, the NLA’s expert panel highlighted evidence that indicated non-HDL cholesterol was a major driver in atherosclerotic disease. Non-HDL is total cholesterol minus HDL cholesterol.
“The international guidelines—European, Canadian, Australian—all are moving in this direction,” he said.
Jacobson emphasized that the AHA/ACC guidelines held value and that debate about the science among physicians was healthy. Physicians can choose what best fits their practices. “There is no reason people shouldn’t follow some the excellent parts of these guidelines but to continue to do LDL targets, continue to monitor LDL, continue to have great patient-provider discussions.”
The expert panels may disagree about patients in the gray zone who have only one or two risk factors, the tools to evaluate risk and what constitutes patient-centered care. Ultimately, though, authors of the NLA recommendations and the AHA/ACC guidelines and practicing physicians share a common goal, and that is to reduce the risk of cardiovascular atherosclerotic disease in patients.