Perspective from Nanette K. Wenger, MD
November 12, 2013
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ACC, AHA recommend statin therapy for four groups

Perspective from Nanette K. Wenger, MD
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A new clinical practice guideline on the management of blood cholesterol released by the American College of Cardiology and the American Heart Association recommends moderate- or high-intensity statin therapy for four groups.

The 2013 Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults breaks from previous practice by not specifying target levels of LDL; instead, it focuses on defining the groups who could benefit the most from lowering LDL, Neil J. Stone, MD, chair of the expert panel that wrote the guideline, said during a press conference.

Statin therapy endorsed

“What our extensive literature review determined was that the evidence supported not only a heart-healthy lifestyle, but the appropriate intensity of statin therapy,” said Stone, of Northwestern University Feinberg School of Medicine. “To simplify this prevention approach for clinical practice, we identified four statin groups.”

The groups are:

  • People with atherosclerosis-related CVD, defined as ACS; history of MI, stable or unstable angina, coronary revascularization, stroke, or transient ischemic attack presumed to be of atherosclerotic origin; and peripheral arterial disease or revascularization.
  • People with LDL ≥190 mg/dL.
  • People with type 2 diabetes aged 40 to 75 years.
  • People with an estimated 10-year risk for CVD of 7.5% or higher aged 40 to 75 years.

A high-intensity statin dose was defined as one in which a daily dose lowers LDL by ≥50%. A moderate-intensity statin dose was defined as one in which a daily dose lowers LDL by 30% to <50%.

The guideline does not recommend cholesterol-lowering medications other than statins with a few exceptions, such as when a patient is statin-intolerant. “We found that nonstatin therapies really didn’t provide an acceptable [atherosclerosis-related] CVD risk reduction benefit compared to their potential for adverse effects and in routine prevention of heart attack and stroke,” Stone said.

Target goals could lead to problems

Target goals were eliminated because they could lead to undertreatment after the goal is met or overtreatment with drugs not shown to reduce CVD, according to information in the guideline.

“Use of LDL targets may result in under-treatment with evidence-based statin therapy or overtreatment with nonstatin drugs that have not been shown to reduce [atherosclerosis-related] CVD events in [randomized controlled trials] (even though the drug may additionally lower LDL and/or non-HDL),” the guideline states. “Implications of treating to an LDL goal may mean that a suboptimal dose of statin is used because the goal has been achieved, or that adding a nonstatin therapy to achieve a specific target results in down-titration of the evidence-based dose of statin for safety reasons. However, when [randomized controlled trial] evidence is available that a nonstatin therapy further reduces [atherosclerosis-related] CVD events when added to statin therapy, the nonstatin therapy may be considered.”

The panel did not make recommendations regarding statin therapy in patients with HF or those undergoing hemodialysis because current literature did not provide enough information on the benefits and risks of statin therapy in those groups.

The estimated 10-year risk for CVD should be calculated using a new ACC/AHA guideline on assessing cardiovascular risk in adults, Stone and colleagues wrote.

For more information:

Stone NJ. Circulation. 2013;doi:10.1161/01.cir.0000437738.63853.7a.

Stone NJ. J Am Coll Cardiol. 2013;doi:10.1016/j.jacc.2013.11.002.

Disclosure: See the full guideline for a list of the panel members’ relevant financial disclosures.