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Explore This IssueMarch 2014
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The “2013 Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults,” released by the American College of Cardiology and the American Heart Association, identifies four groups of people who are most likely to benefit from statin therapy, recommends high-intensity and moderate-intensity statin therapy doses for secondary and primary prevention, and notes that there is no evidence from randomized controlled trials to support specific low-density lipoprotein (LDL) cholesterol or non–high-density lipoprotein (HDL) cholesterol treatment targets.1
The guideline reiterates the “strong evidence” related to the benefit of statin therapy for patients at risk of atherosclerotic cardiovascular disease (ASCVD), according to Jorge Plutzky, MD, director of the Vascular Disease Prevention Program and associate professor at Harvard Medical School in Boston. “We do not have definitive evidence that patients with rheumatologic diseases are at as high a risk as patients with diabetes; however, there is a lot of interest in the notion that they do have increased cardiovascular risk.
“Rheumatologists should see [this guideline] as support for considering starting therapy for their patients with rheumatologic diseases and inflammatory disorders and for using statins at appropriate doses,” Dr. Plutzky says.
Reduction in ASCVD Risk
The guideline is based on data from randomized controlled trials as well as systematic reviews and meta-analyses of randomized controlled trials. It focuses on lipid management for the reduction in risk of ASCVD and reiterates the importance of a heart-healthy diet, regular exercise, avoidance of tobacco, and maintenance of a healthy weight as critical components in risk reduction. Additionally, the guideline makes clear that nonstatin therapies “do not provide acceptable risk reduction benefits compared with their potential for adverse effects in routine prevention of ASCVD.”1
Physicians are encouraged to use a new risk calculator developed for the guideline to assess a patient’s 10-year risk of ASCVD (defined as first occurrence of nonfatal and fatal myocardial infarction and nonfatal and fatal stroke).2 The calculator assesses risk based on blood pressure, smoking and diabetes status, age, and sex; it can be used to predict stroke and coronary heart disease events in non–Hispanic Caucasian and African-American women and men aged 40 to 75 years, with or without diabetes, who have LDL cholesterol levels of 70 to 189 mg/dL. The guideline underscores the importance of statin therapy for patients with diagnosed ASCVD—defined as coronary heart disease, stroke, and peripheral arterial disease—and for those with primary lipid disorders.
Controversy about the validity of the risk assessment algorithm for other individuals and whether it overestimates risk, a recent topic of debate in medical journals and other venues, has added an unintended level of confusion about its use in clinical practice.3,4 Even though statins appear safe and effective “in the vast majority of patients taking them, the new guideline has added confusion, not clarity, regarding appropriate patient selection,” says Daniel Solomon, MD, MPH, chief of the section of clinical sciences in the division of rheumatology at Brigham and Women’s Hospital in Boston, and professor of medicine at Harvard Medical School. “The controversy over the risk calculator needs to be resolved before most doctors will change their practice,” he says, adding that he doubts that physician behavior will change until the American Heart Association and the American College of Cardiology clarify the validity of the calculator.