|Game Changer! The New ACA/AHA Cholesterol Guidelines|
|By Jeffrey E. Keller MD|
About a year ago, the American Heart Association released new cholesterol management guidelines. These guidelines changed how we practitioners should deal with cholesterol evaluation and management almost to a revolutionary degree. They are a BIG departure from past thinking. For example, under the old system, we practitioners were supposed to follow cholesterol labs. We were supposed to get LDL levels down below 100. Not anymore! In fact, under the new guidelines, once you have started someone on therapy, you really don’t have to check their cholesterol ever again! Really!
Also, the new guidelines say that there is basically only one therapy for almost all lipid patients: statins. According to the new guidelines, we should get rid of all other lipid therapies. Niacin? Throw it away. Gemfibrozil and fish oil? Get rid of them.
What about triglycerides? The new guidelines say that you should only treat hypertriglyceridemia with medications when the triglyceride level is greater than 1000mg/d. Holy cow, 1000! Where did that come from?
This document is almost revolutionary in its sweeping changes. It makes treating hyperlipidemia so very much easier. In my opinion, all correctional practitioners and nurses involved in chronic care clinics should know the new guidelines. If you have not already done so, you need to re-write your lipid protocol.
Where did the new cholesterol guidelines come from?
The cholesterol guidelines that most practitioners have relied on in the past were written by the National Heart, Lung and Blood Institute (NHLBI) in 2001 and updated in 2004. Of course, a lot of research has happened since 2004 and it was apparent that the old guidelines were out-of-date. The NHLBI began writing an updated version but half way through they decided to get out of the guideline-writing business. Fortunately, the American College of Cardiologists and The American Heart Association (ACC/AHA) stepped in to finish the project. Their final report was entitled: 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults.
What new data influenced the ACC/AHA to change their guideline recommendations?
It has long been known that people with bad cholesterol numbers (high total cholesterol, low HDL or high LDL) have an increased incidence of bad medical outcomes such as death, heart attacks and strokes. What was not known for sure was whether having high cholesterol caused that heart attack or was merely associated with it.
I have found that this distinction between causation and association is hard for many people to wrap their heads around. However, here are two good examples can make the distinction clear: People who have a lot of ashtrays in their house have an increased risk of heart attacks. But if you take the ashtrays out of the house, the incidence of MI will not change. This is because the ashtrays are not causing the heart attacks; smoking is. And it just so happens that smokers tend to use ashtrays. So the ashtrays are associated with heart attacks but do not cause them.
Similarly, people with gray hair have an increased risk of dying, but if you dye their hair brown, it will not decrease their risk of death—because, of course, the factor here increasing health risk is age, not hair color directly.
So, that leads us to this fundamental question: does high total cholesterol directly cause heart attacks, strokes and death? We have long believed this and assumed that any reduction in bad cholesterol numbers would translate to decreased risk of heart attacks, stroke and death. This led to the previous guidelines focusing on cholesterol numbers. According to the old guidelines, total cholesterol should be reduced—by any means possible—to less than 200. LDL should be less than100. HDL should be greater than 60.
However, the two main findings of cholesterol research in the last decade are these:
What drugs should be used in the treatment of cholesterol?
This one is easy. As I have already said, there is just one class of call of drugs to treat high cholesterol in the vast majority of cases: statins. Everything else, you can pretty well forget. The new ACC/AHA guidelines also do not endorse any one statin over another, so you can ignore the TV ads and use the inexpensive generics without guilt.
And according to the new guidelines, you should get rid of everything else, like niacin, fibrates, fish oil and the rest. Here is their one-sentence quote on the matter:
The guidelines follow up this statement by citing the studies that support this statement. If you are interested, you can look them up. But in the meantime, this could be a great cost-cutting initiative in your facility! Identify those patients in your system who are on non-statin cholesterol agents and discontinue them.
The only real question in the new guidelines is whether you should use “high dose” or “medium dose.” More on that later.
Who should be treated with a statin?
According to the new ACC/AHA guidelines, there are four groups of patients who should be prescribed a statin. Memorize these:
What about lipid levels? When should I order them?
One of the main changes in the new cholesterol guidelines is the de-emphasis on following cholesterol numbers. It used to be that we treated until we achieved a number goal, such as an LDL of less than 100 and an HDL of more than 60. The new guidelines make these targets, for the most part, irrelevant. So when are lipid numbers useful under the new guidelines?
Once a patient is on statins, since you are not treating to a goal number, you really never have to check their cholesterol numbers ever again. The ACC/AHA guidelines say that the main reason to recheck cholesterol numbers after the initiation of statin therapy is “to determine a patient’s adherence.” But in corrections, we already know whether our patients are taking their medications. We just have to look at the Medication Administration Record!
I suspect that many of us will continue to get the yearly cholesterol tests in patients already taking statins, because it is so ingrained as a habit. Just recognize that you now don’t have to. If you are looking for ways to save a little money at your facility—well, this now fits under the category of “unnecessary testing” for many patients.
What dose of statin should we prescribe?
This also is pretty simple. Based on an individual patient’s cardiovascular risk, the AHA/ACA recommends that you start either “moderate-intensity” statin therapy or “high-intensity statin therapy.” I will not summarize which patients fit in each category; you can look that up later (I’ll attach a reference table at the end of this article). However, note that there is no recommended “low-intensity” statin therapy. Many of our patients are on too low of a dose of statins according to these guidelines.
Corrections.com author, Jeffrey E. Keller is a Board Certified Emergency Physician with 25 years of practice experience before moving full time into the practice of Correctional Medicine. He is the Chief Medical Officer of Centurion. He is also the author of the "Jail Medicine" blog
Other articles by Keller
IN CASE YOU MISSED IT