In November 2013, the American Heart Association and the American College of Cardiology released new guidelines for prevention of cardiovascular disease. These have gotten quite a bit of media attention and were met with varying responses from the healthcare community. We wanted to offer a clear summary to our customers (and make sure that we on the wellness team fully understood the changes). Interestingly, it proved very difficult to access the actual document containing the guidelines. All the media articles linked to the American Heart Association website which has a link to a very long, scientific paper about the CREATION of the guidelines. It does not provide the guidelines themselves. In order to access the actual guidelines, you had to read the above paper, and find the footnoted link in the middle of the document that took you to another very long paper in scientific language that discussed the actual guidelines and the rationale behind them. Here is a link to the actual guidelines.
Why did they make new guidelines?
Past guidelines were based on older research using primarily white males as subjects. This meant that the guidelines were not necessarily as accurate for women, African Americans, Hispanics or Asians. Guidelines were also a “treat to target” structure, using LDL as a benchmark, working on the assumption that lower LDL was better. The intent of the update was to have guidelines that were more relevant to women and non-whites, as well as reviewing the past assumption of “treat to target” (treat until is LDL below 100). New guidelines were made by reviewing new research up through 2011 (nothing past 2011 was used).
What are the guidelines really for?
Guidelines are primarily intended as a guide to prescribing statin drugs. They are NOT intended to be a comprehensive guide to diagnosis, treatment or prevention of cardiovascular disease or atherosclerosis (CVD, AS). According to the paper, “these guidelines were never intended to be a comprehensive approach to lipid management for purposes other than ASCVD risk reduction.” The guidelines are intended to help prescribers determine which patients are at high enough risk for CVD and cardiovascular events (stroke, heart attack) that the benefit of taking statins, outweighs the risk of side effects. The guidelines are also to help prescribers know what dose of statins to use with these higher risk groups.
What did the research say?
Overall, they did not find research support for using statins to lower LDL’s to target levels. Yes, you heard that right. They found that using statins to lower LDL’s below 100 did NOT reduce risk of CVD. This recommendation from previous years have been dropped. They no longer recommend “treat to target.” This is a big deal. Otherwise they used research on women and African Americans to make slight changes in the mathematical calculations done to assess 10 year risk of having a non-fatal cardiovascular event. Please note, they still do not have clear guidelines for Asians, Hispanics or Native Americans. They acknowledged that these groups have significantly different risk ratios than whites, and that the calculator results for these groups should be considered in this context.
Studies also found that there was no benefit to using adjunct therapies (adding niacin to statins) in order to further lower LDL, HDL, cholesterol, or triglycerides. They also did not find benefit to use of statins beyond the age of 75.
OK, so what are the actual guidelines?
1) Diet and lifestyle are recommended as “critical component” and “background” therapy either before or in conjunction with statin therapy. These are defined as a heart healthy diet, regular exercise, avoidance of tobacco and maintaining healthy body weight.
a. It is important to note that this was their number one recommendation. They were clear that diet and lifestyle could not be ignored, even when statins were being prescribed. As holistic health advocates, we are big fans of this recommendation and are really happy to see it listed first!
2) They identified 4 high risk groups that should benefit from statins, and for whom benefit of statins should outweigh the risk of taking statins. There is an algorithm on the websites above that leads prescribers through identifying these groups and makes suggestions for stain dosing. The risk groups are identified as follows:
a. Patients who already have ASCVD (atherosclerotic cardiovascular disease)
b. LDL over 190 (this is a radical change from previous recommendations for LDL target below 100 or even below 60!)
c. Adults with diabetes (type 1 or 2) AND with LDL above 70
d. Total ASCVD 10 year risk over 7.5% (based on the calculator- discussed below)
Statins are now recommended if 10 year risk exceeds 7.5%, previously statins were recommended if 5 year risk exceeded 10%. This represents a drop in threshold for recommending statins and is the focus of the controversy and conversation in the medical field. The concern is that it may mean an increase in the number of patients that are prescribed statins. Some feel confident the data supports this change, and that it will improve outcomes for this re-defined risk group. Some worry that increased prescribing may be unwarranted.
3) Updated calculator:
a. The previous risk calculator was based on the Framingham studies. It took into consideration: age, gender, HDL, total cholesterol, systolic blood pressure, if you are on blood pressure reducing medicine, and smoking status.
b. The new calculator is very similar. It has the addition of considering race (white or African American), and diabetes status. The math behind the calculator does vary as it is supposed to take new data into consideration.
c. The calculator is to be used for white & black adults WITHOUT current ASCVD. It can be used for other races, but is slightly less accurate.
d. The link to the calculator is here.
The wellness team did some experimenting with the calculator. We found the calculator easy to use and that the 10 year risk scores seemed accurate for each of us. The calculator also provides a “lifetime risk” score, which we had a harder time interpreting. There are NO recommendations for prescribing statins based on these “lifetime risk” numbers. All recommendations are based on the 10 year risk numbers, which appear to us to be reasonably accurate. The consensus in the health care community seems to be that the new guidelines are reasonable as a guide, and as always should be considered with all parts of a patients story before making clinical decisions regarding prescriptions.
by Becky Andrews, ND*. Becky is available for consultation at the Central Peoples location.
*Naturopathic doctors are not currently licensed in the state of Texas.