Last week, the AAFP posted its qualified endorsement of the American College of Cardiology (ACC) and American Heart Association (AHA) guidelines on treatment of high cholesterol(circ.ahajournals.org) to reduce atherosclerotic cardiovascular risk in adults. AAFP News reported on the guidelines when they first published last November.
On June 11, AAFP President Reid Blackwelder, M.D., of Kingsport, Tenn., participated as a panelist in a webinar hosted by Prescriber's Letter. The webinar, "PL Voices: The Current Cholesterol Controversy(info.therapeuticresearch.com)," covered multiple topics, including a comparison of cholesterol management recommendations from the ACC/AHA, the National Cholesterol Education Panel (ATP III) and the National Lipid Association. Among other topics discussed were the relationship between LDL cholesterol and cardiovascular risk and clinical situations in which statins should be used to lower cardiovascular risk.
The invitation to participate on the panel came as a result of the webinar host's recognition that family physicians would constitute a considerable proportion of the physicians implementing the guidelines, said Blackwelder.
"Prescriber's Letter recognized that it is critical to have family physicians, the experts at the frontline, translating the recommendation to meeting patient need," he told AAFP News.
The biggest and most significant difference in the new guidelines, according to Blackwelder, is that they are much more patient-centered.
- The AAFP recently endorsed, with qualifications, guidelines from the American College of Cardiology (ACC) and American Heart Association (AHA) on treatment of high cholesterol to reduce atherosclerotic cardiovascular risk in adults.
- On June 11, AAFP President Reid Blackwelder, M.D., participated as a panelist in a webinar hosted by Prescriber's Letter that included discussion of the new ACC/AHA guidelines.
- The AAFP's endorsement of the cholesterol management guidelines came with three qualifications that concerned the fact that some recommendations were based on expert opinion, a number of guideline panelists had conflicts of interest and the risk assessment tool used has not been properly validated.
"They are based on good evidence about patient outcomes rather than merely lab test numbers," he said. "The old guidelines were treating to goals of certain numbers, which of course isn't what we do. We don't treat numbers; we treat patients.
"So these new guidelines really allow us to say, 'We know the evidence supports the use of these statin drugs at a high dose to avoid a major cardiovascular event such as a heart attack or a stroke -- that is, to improve your outcome.' This is opposed to the past guidelines, which had titration of doses to achieve certain levels of LDL and following other lab tests -- none of which offered any evidence to support those decisions as improving patients' outcomes of decreased heart attacks and strokes."
Because getting to a specific LDL goal is no longer a critical factor, "there is a little bit of controversy about how often you check lipid profiles," said Blackwelder. "In the old days, treating to goal -- it was really critical to see if you got to that goal LDL number."
Webinar panelists who had been on the guideline creation team thought that checking the lipid profile and liver enzymes initially was reasonable, Blackwelder noted. "But physicians shouldn't worry about liver enzymes over time," he said. Instead, the guideline panel recommended checking a lipid panel every three to 12 months, mainly as a means of gauging patient adherence.
"Patients have been trained for a while to follow numbers and there is nothing wrong with connecting back into that habit," Blackwelder observed. "Patients like to see positive outcomes even though the main outcome is preventing a heart attack. I think there can be a benefit that can reinforce for patients that we've made progress."
Still, it's important for family physicians to educate patients about the new end goal, which is to avoid cardiovascular events. "I don't want my patients to feel like they are failing if they don't get to the LDL number that in the past they have been told is their goal," he said. "The main reason to check it is to create an opportunity to talk about adherence. We are comfortable doing this through our conversations, questions and team-based approaches to patient care, rather than solely through the results of a blood test. Adherence is best seen as a social and lifestyle issue rather than as a lab result."
The AAFP's endorsement of the high cholesterol management guidelines came with three qualifications, which resulted from following the Academy's thorough review process. The AAFP doesn't endorse other organizations' guidelines without performing its own independent review, Blackwelder said.
The first qualification concerned the fact that many of the recommendations were based on expert opinion rather than more rigorous research results (randomized controlled trials, in particular), although the key points are based on high-quality evidence. "There were 54 points, and a significant amount of them were (based on) expert opinion, which is the weakest form of evidence," he said. "However, we felt comfortable that the most important guidelines were based on very good evidence."
The second qualification involved the fact that seven of the 15 members of the guideline panel, including one of the vice chairs, acknowledged having conflicts of interest that mainly consisted of serving on speakers bureaus or getting research grants from the pharmaceutical industry.
"One of the key recommendations that (the AAFP follows) is you should minimize or avoid conflicts of interest, especially with a topic area like this," said Blackwelder. "Eight of the members had managed their conflicts with industry by changing their connections several years previously."
The final qualification concerned a cardiovascular disease (CVD) risk assessment tool the guideline used. The tool has not been appropriately validated, the AAFP noted, and could overestimate risk. Specifically, compared with the previously accepted risk cutoff of 10 percent, the new tool uses a risk cutoff of 7.5 percent, which would significantly increase the number of people on statins.
Because this is a new tool, Blackwelder noted, there are not years of data to analyze, which leads to uncertainty.
"However, we recognize that the tool essentially incorporates the longest-running tool -- (based on the) Framingham (study results) -- and seems to add to it, basically reflecting long-standing recognition that all of the risk factors that we have paid attention to over the years are still the main ones," he said.
Blackwelder said the AAFP suggests that family physicians use any risk assessment tool as a starting point and then contextualize the tool's results for each patient. "What this does is really create the foundation for and reinforce what we all know as family physicians -- that it's about the nature of our relationship with our patients and the conversations these relationships nurture," he said.
"The most important trend is toward shared decision-making."