Cholesterol

Management of Blood Cholesterol

(Affirmation of Value, December 2020)

The “VA/DOD Clinical Practice Guideline for the Management of Dyslipidemia for Cardiovascular Risk Reduction” was developed by the US Department of Veteran Affairs and the Department of Defense and categorized as Affirmation of Value by the American Academy of Family Physicians.  

Key Recommendations

• All adults should receive counseling on healthy diet and lifestyle to reduce risk of cardiovascular disease (CVD). 
• CVD risk screening should include a lipid profile and a risk calculation*. 
• Routine screening for dyslipidemia outside of the context of a cardiovascular risk assessment is not recommended.
• Individuals with an increased 10-year risk for cardiovascular disease (greater than 12%) should be counseled on healthy diet and lifestyle modifications to reduce risk. Additionally, shared decision making should be conducted to determine options for moderate intensity statins for primary prevention, if desired by the individual. 
• Individuals with established atherosclerotic cardiovascular disease (ASCVD) should be treated with a moderate-dose statin following a shared decision-making discussion of benefits and harms. Routine use of non-statin lipid lowering drugs are not recommended. 
• Routine monitoring of lipid level goals as part of secondary prevention is not recommended for individuals with established ASCVD. 
• Individuals may be offered a high-dose statin only in select instances (e.g., ACS, multiple uncontrolled risk factors or recurrent CVD events on moderate-dose statin) following a discussion of the additional harms, small additional benefits, and patient preferences.

The AAFP uses the category of “Affirmation of Value” to support clinical practice guidelines that provide valuable guidance, but do not meet our criteria for full endorsement. The primary reasons for not endorsing this guideline included:

*While risk-based recommendations allow for more patient-centered discussions and treatment decisions, many calculators used to assess risk include race/ethnicity as a factor. The AAFP recognizes that these calculators are limited by their reliance on race as a risk factor and issues a strong call for research for methods to accurately assess risk based on social determinants of health and racism instead of race. The AAFP opposes the use of race as a proxy for biology or genetics in clinical evaluation and management and the following policy opposing the inappropriate use of race in clinical decision making: https://www.aafp.org/about/policies/all/racebased-medicine.html

• The guideline possessed small methodological flaws and issued several recommendations without strong evidence.
• Screening recommendations were not completely aligned with current AAFP-supported USPSTF recommendations for dyslipidemia.