[TLKeymaster]

This week, the American College of Cardiology and American Heart Association (ACC/AHA) released new guidelines for the management of Lipids.

The new guidelines are a major shift in thinking. They are far closer to the proposed POQ in the discussion above than to the previous guidelines. Spooky. This is clearly cause and effect. Who would have thought we had that much influence?

Key points in new guidelines.
Treating to LDL cholesterol targets is no longer recommended.

Patients should receive Statins if they fall into one of these four groups.

• Patients with clinical atherosclerotic cardiovascular disease (ASCVD) should receive high-intensity (age, <75) or moderate-intensity (age, ≥75) statin therapy.
• Patients with LDL cholesterol levels ≥ 4.9 mmol/L should receive high-intensity statin therapy.
• Diabetic patients aged 40–75 with LDL cholesterol levels of 1.8–4.9 mmol/L and without clinical ASCVD should receive at least moderate-intensity statin therapy (and possibly high-intensity statin therapy when estimated 10-year ASCVD risk is ≥7.5%).
• Patients without clinical ASCVD or diabetes but with LDL cholesterol levels of 1.8-4.9 mg/dL and estimated 10-year ASCVD risk ≥7.5% should receive moderate- or high-intensity statin therapy.

High-intensity statin therapies are atorvastatin (40–80 mg) or rosuvastatin (Crestor; 20–40 mg). Moderate-intensity statin therapies include atorvastatin (10–20 mg), rosuvastatin (5–10 mg), simvastatin (20–40 mg), pravastatin (40–80 mg), and several others.

With few exceptions, use of lipid-modifying drugs other than statins is discouraged.

Lifestyle modification is recommended for all patients, regardless of cholesterol-lowering drug therapy.

These guidelines use a new ten year risk calculator which includes both coronary events and stroke, and is only available as an Excel spreadsheet currently.
This is different to the calculators used in Australia, as per another discussion on this site.

[TLKeymaster]

Thanks Dan,

The studies quoted by Ben confirm that the benefits of statins are unrelated to the baseline LDL level, but they do have some benefit in primary prevention. The extent of that benefit is dependent on absolute cardiac risk.

Measuring lipids once to determine absolute cardiac risk (at age 35-55) seems like a valid recommendation.
Improve the factors that can be improved (smoking, blood pressure).
If risk remains > X %, Statins may be indicated in primary prevention. (is X = 15%?)

[TLKeymaster]

James McCormack (of http://therapeuticseducation.org, my favourite podcast) has a Risk Calculator at

http://bestsciencemedicine.com/chd/calc2.html

This shows the effect of different treatments on risk, and displays the risk pictorially. Even though it is in beta, it is worth a look.

The algorithm used in this tool (and the Australian cvdcheck.org.au tool) uses Framingham data.

In New Zealand, the team lead by Rod Jackson at the University of Auckland are collecting their own data from primary care and calculating their own algorithm. I like this model. They have accumulated a very large database. Their tool is available at
Heart Forecast Online. Note that you are meant to be a kiwi to use it – c’mon the All Blacks.

I guess, Dan, using these tools depends on what changes as a result.
For primary prevention –

• Control your blood pressure
• Don’t smoke
• Exercise regularly
• Consider a Statin, Aspirin if high risk > 15%

What else works?

As far as age specific risk goes, I don’t believe we have any data on people aged younger than 45. I’m not sure a 29 year old could have a 9% risk, but I get your point.

There has been some debate in NZ over whether lifetime risk should be used rather than 5 or 10 year risk. The problem for that is that for most men, lifetime risk approaches 100%!

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