May 2014

Health & Wellness: New Cholesterol Guidelines: What Do They Mean for You?

Author: William E. Kyle, D.O

If you’ve been monitoring your cholesterol numbers, you now have some new guidelines to follow. The guidelines, which were recently issued by the American College of Cardiology and the American Heart Association, represent a significant change in the way healthcare providers treat cholesterol levels in order to decrease their patients’ cardiovascular risk.

Out with the old, in with the new
First, let’s look at how the old guidelines worked. If you are 20 years old or older or you have some reason (e.g., diabetes, high blood pressure, heart disease) to have your cholesterol checked, you probably were screened initially with a fasting panel. The results of this lipid panel helped decide whether a statin medication, such as Lipitor, Crestor or Zocor, was prescribed to help control your cholesterol levels.
Physicians made the decision to treat cholesterol based on a risk calculation called the Framingham Risk Score or on your LDL (low density lipoprotein) number, also called “bad cholesterol.” Once we started treatment with a statin medication, we would adjust your dose depending on your LDL number.
The new guidelines still recommend screenings with some minor changes, but they totally abandon the idea of treatment based on your LDL number. Instead, they advise physicians to treat patients based on their cardiovascular risk only. This puts patients into four categories:

1. Individuals with clinical atherosclerotic cardiovascular disease.**
2. Individuals with LDL levels ≥ 190 mg/dL, such as those with a family history of hypercholesterolemia (high cholesterol).
3. Individuals 40 to 75 years of age with diabetes and LDL 70 to 189 mg/dL without clinical atherosclerotic cardiovascular disease.
4. Individuals without clinical atherosclerotic cardiovascular disease or diabetes who are 40 to 75 years old with an LDL 70 to 189 mg/dL and have an estimated 10-year risk of atherosclerotic cardiovascular disease of 7.5 percent or higher.

Your patient category then determines the strength (moderate or high-intensity) of the statin you are prescribed. Along with these guidelines, a new risk calculator has been created to replace the Framingham Risk Score. Finally, the guidelines still recommend we monitor your LDL cholesterol, but only to make sure there has been a drop in the levels and not to adjust statin dosages.

Addressing the controversies
Physicians welcome the new guidelines, which were needed, but there has been some controversy on two aspects: the fourth patient category and the new risk calculator.

Some physicians question the recommendation to treat healthier patients with a low 10-year heart disease risk of 7.5 percent or higher. They think it will be difficult to start a patient on a statin at such a low threshold when he or she actually looks quite healthy on paper.

A report from the National Health and Nutrition Examination Survey, which was conducted between 2005 and 2010, contains data based on heart disease risk factors and heart disease rates among 3,773 people. It showed 56 million Americans between the ages of 40 and 75 would be eligible for statins, compared to 43.2 million under the older recommendations—an increase of nearly 13 million patients. If this is true, then the new guideline represents one of the greatest changes we have seen in decades.

The issue with the new risk calculator is that it has never been validated or compared to the Framingham Risk Score, which makes it difficult to know how accurate it is in identifying new patients at risk. The main new variables used in this calculation are race, smoking status, and slightly different age cutoffs.
One change has not been challenged, though. The new guideline to abandon LDL targets and to treat only based on cardiac risk with moderate or high-intensity doses of statins is evidence-based and well-documented.

The new guidelines and you
So, what do the new guidelines mean for you? Probably not much if you have a moderate to high risk for cardiovascular disease; you will likely fit well within these guidelines. For healthy individuals who have a slightly increased risk (7.5 percent or higher), your physician may recommend treatment, although the calculation has not yet been well validated. That decision is best made by you and your doctor. 

William E. Kyle, D.O., is an internal medicine physician who is in practice at Memorial Health University Physicians – Legacy Center, 14 Okatie Center Blvd. S., Suite 101, in Okatie. He can be reached at (843) 836-3800.

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