Follow the Leader
Setting: American College of Cardiology(ACC) 62nd Annual Scientific Session, San Francisco, CA March 9-11, 2013
A packed crowd, spilling out into the foyer of the lecture hall, awaited the much anticipated release of the new 2013 ACC/AHA Blood Cholesterol Guidelines. They weren’t quite ready and they were not released at that time, so a Q&A session with the Guideline writing committee members was held instead, offering a hint of what we might expect from these guidelines.
Based on what they had already heard, an audience participant asked one of the Guideline writers what they would do in the following situation:
A patient who had had an ASCVD event who was placed on a maximum high intensity statin, like Atorvastatin 80 mg daily, but achieved an on-treatment LDL-C of just over 100 mg/dL (previous guidelines called for LDL
Flying Under the Radar
Why do these cases go undertreated?
“But my doctor is following the guidelines - is it possible that I am being undertreated?” Yes, it is. Providers are human and they often “follow the leader.” When it comes to cardiovascular guidelines, the leader is often the American College of Cardiology and the American Heart Association (ACC/AHA).
However guidelines are just that - guidelines. They don’t always apply to everyone (for instance, certain ethnic groups - see below). They don’t always apply to every situation. There are many of them out there and they’re not always created equal. And yes, as well respected as these organizations are, sometimes they get it wrong. That was the case with the 2013 ACC/AHA Blood Cholesterol Guidelines. They were well intentioned and they had their reasons, but it was a swing and a miss and set the lipid community back several years.
Fortunately, medicine is a team sport. Other stakeholders picked up the baton, ran with it and tried to make up for lost ground.
A checklist of targeted recommendations based on published guidelines
Cardiawareness Advocate Checklist:
(For patients and providers)
- Know your baseline risk
- Highest Risk - we adhere to the most aggressive guidelines (ESC, NLA, AACE/ACE
- Secondary prevention:> 20% ten year risk of ASCVD event. The Repeat Offender
- CAC > 300: Carries similar risk as “heart attack survivors”
- Familial Hypercholesterolemia: Hiding in Plain Site - Familial Hypercholesterolemia
- Elevated Lp(a) > 325 nmol/L Little Napoleon Complex - Lipoprotein (a)
- High Lifetime risk
- > 75th percentile rank on Coronary Artery Calcium Score: A Picture is Worth a Thousand Words - Coronary Artery Calcium Scores
- Mayo Clinic Statin Choice Decision Aid: Statin Choice Decision AID - Site
- Contains multiple Risk calculators to include:
- ACC/AHA PCE
- Reynolds (includes family history and hs CRP)
- Framingham
- European: HeartScore
- Consider multiple guidelines
- Choose the guideline(s) most applicable to the individual being treated
- Consider Expert Opinion within the framework of a patient-centered discussion with your care team members.
- Primordial prevention: There is urgent need to treat atherosclerotic cardiovascular disease risk earlier, more intensively, and with greater precision: A review of current practice and recommendations for improved effectiveness - ScienceDirect
- If in doubt, seek expert advice from a cardiometabolic specialist or lipidologist
Going into detail on the evidence behind the recommendations and history of treatment for this phenotype.
The 2013 ACC/AHA Blood Cholesterol Guidelines were created under the strictest interpretation of “Evidence Based Medicine,” allowing only for data obtained from Randomized Controlled Trials (RCT) and/or meta-analysis of Randomized Controlled Trials in crafting recommendations. This painted them into a corner and effectively created a situation where they undermined existing guidelines and were forced to abandon any sort of lipid goal or target. Instead, they vehemently declared that clinical trials to date had only shown that a particular dose of statin had achieved the positive outcomes, rather than a particular LDL-C goal attained, for instance.
What led to the ACC/AHA producing the 2013 Blood Cholesterol Guidelines is an interesting story. Since 1985 the National Cholesterol Education Program has been managed by the NHLBI, a division of the NIH and produced guidelines on cholesterol. The last guideline published was the Adult Treatment Panel III (NCEP ATPIII) in 2001 and updated in 2004 (ATP III Report on High Blood Cholesterol) to include an optional goal of LDL-C