Neil J. Stone, MD; Jennifer G. Robinson, MD, MPH; Alice H. Lichtenstein, ScD; David C. Goff Jr., MD, PhD; Donald M. Lloyd-Jones, MD, ScM; Sidney C. Smith Jr., MD; Conrad Blum, MD; J. Sanford Schwartz, MD; for the 2013 ACC/AHA Cholesterol Guideline Panel *
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-0126.
Corresponding Author: J. Sanford Schwartz, MD, University of Pennsylvania, Blockley 1101, 423 Guardian Drive, Philadelphia, PA 19104; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Stone: Feinberg School of Medicine, Northwestern Medical Faculty Foundation, Northwestern University, 676 North St. Clair, Suite 600 (Cardiology), Chicago, IL 60611.
Dr. Robinson: Department of Epidemiology, University of Iowa, 200 Hawkins Drive, SE 226 GH, Iowa City, IA 52242
Dr. Lichtenstein: Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, 711 Washington Street, Boston, MA 02111.
Dr. Goff: Colorado School of Public Health, University of Colorado, Building 500, 3rd Floor, Suite 300, Anschutz Medical Campus, Aurora, CO 80045.
Dr. Lloyd-Jones: Department of Preventive Medicine, Northwestern University, 680 North Lake Shore Drive, Suite 1400, Chicago, IL 60611.
Dr. Smith: UNC Health Care System, 101 Manning Drive, Chapel Hill, NC 27514.
Dr. Blum: Columbia College, P & S, 16 East 60th Street, New York, NY 10022.
Dr. Schwartz: University of Pennsylvania, Blockley 1101, 423 Guardian Drive, Philadelphia, PA 19104.
In November 2013, the American College of Cardiology and American Heart Association (ACC/AHA) released a clinical practice guideline on the treatment of blood cholesterol to reduce cardiovascular risk in adults. This synopsis summarizes the major recommendations.
In 2008, the National Heart, Lung, and Blood Institute convened the Adult Treatment Panel (ATP) IV to update the 2001 ATP-III cholesterol guidelines using a rigorous process to systematically review randomized, controlled trials (RCTs) and meta-analyses of RCTs that examined cardiovascular outcomes. The panel commissioned independent systematic evidence reviews on low-density lipoprotein cholesterol and non–high-density lipoprotein cholesterol goals in secondary and primary prevention and the effect of lipid drugs on atherosclerotic cardiovascular disease events and adverse effects. In September 2013, the panel's draft recommendations were transitioned to the ACC/AHA.
This synopsis summarizes key features of the guidelines in 8 areas: lifestyle, groups shown to benefit from statins, statin safety, decision making, estimation of cardiovascular disease risk, intensity of statin therapy, treatment targets, and monitoring of statin therapy.
Table 1. Major Recommendations for the Treatment of Blood Cholesterol to Reduce ASCVD Risk in Adults*†
Table 2. High-, Moderate-, and Low-Intensity Statin Therapy*
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David L. Keller, MD, MS, FACP
March 5, 2014
Should we monitor statin blood concentrations instead of LDL ?
Patients who are at risk of adverse events due to atherosclerotic vascular disease (ASVD) are treated with statins, which have been well-proved to reduce these risks. Until now, physicians were told to treat these patients to goals based on blood levels of LDL cholesterol. Now, we are told that the evidence does not support treating to LDL goals, but rather dictates that certain doses of statin be administered, based on the doses which were used in clinical trials.
All medications work by some pharmacological effect. Prior guidelines were based on the assumption that lowering the LDL cholesterol concentration in the blood was the beneficial mechanism. This hypothesis implied that other types of medications should be as effective as statins at reducing adverse ASVD event rates, for equal degrees of LDL-lowering. If this has been disproved, then the new guidelines are reasonable to emphasize statin dose rather than LDL level as the treatment goal.
However, we can and should strive to quantify and normalize our statin treatment for each patient. If the pharmacological benefit of statin therapy is caused by the concentration of the statin in the blood, rather than by blood LDL levels, we should be measuring and monitoring statin levels now, instead of LDL levels. Otherwise, we are treating patients blindly.
A given dose of statin will result in very different blood concentrations of that statin in different individuals, depending on their renal and hepatic functions, their body mass, their cytochrome genetics, and on other factors. To account for these differences in each unique patient, blood statin concentrations would seem to be required to most precisely maximize the benefits and minimize the risks for each patient.
Stone NJ, Robinson JG, Lichtenstein AH, Goff DC, Lloyd-Jones DM, Smith SC, et al. Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Disease Risk in Adults: Synopsis of the 2013 American College of Cardiology/American Heart Association Cholesterol Guideline. Ann Intern Med. ;160:339–343. doi: 10.7326/M14-0126
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Published: Ann Intern Med. 2014;160(5):339-343.
Cardiology, Coronary Risk Factors, Dyslipidemia, Guidelines.
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