AAFP Affirms Value of New Cholesterol Management Guideline

ACC/AHA Guidance Doesn't Meet Standards for Full Academy Endorsement

March 20, 2019 01:37 pm Chris Crawford – The AAFP recently gave its "affirmation of value" designation to a cholesterol management guideline from the American College of Cardiology (ACC) and the American Heart Association (AHA) that was published last November simultaneously in the Journal of the American College of Cardiology and the AHA's journal Circulation.

The guideline includes, among other things, recommendations for more personalized risk assessments and new cholesterol-lowering drug options for people at the highest risk for atherosclerotic cardiovascular disease (ASCVD).

AAFP Commission on Health of the Public and Science member James Stevermer, M.D., of Fulton, Mo., told AAFP News that the Academy didn't participate in the development of this guideline because the methods that the ACC/AHA planned to use were not consistent with the Academy's standards for creating guidelines.

"The Commission on Health of the Public and Science did not think the ACC/AHA guideline met the AAFP's standards for endorsement of guidelines," Stevermer said. "However, this guideline does have valuable information and will be influential in the medical community, so we identified it as a guideline with parts that family physicians may well find helpful."

Story Highlights

Among primary reasons the Academy did not endorse this guideline are that

an independent systematic review only addressed a small portion of the recommendations primarily focused on the addition of non-statin therapy; and
many recommendations were based on low-quality or insufficient evidence, such as those addressing specific target levels for treatment and the use of coronary artery calcium scoring for decision-making.

This guideline, which has been approved by multiple other health groups, updates the ACC/AHA's 2013 guideline on managing blood cholesterol, which the AAFP endorsed with qualifications. Similar to the current guideline, the endorsement with qualifications designation was given to that previous guideline because of concerns about the methodology.

Recommendations in the updated guideline were based largely on a systematic literature review that examined adding other medications to statins to lower lipid levels and decrease cardiovascular morbidity. Other recommendations were based on the previous guideline, individual studies or expert opinion.

For additional context, the Academy supports the U.S. Preventive Services Task Force's (USPSTF's) recommendation statement on statin therapy for the primary prevention of cardiovascular disease.

Key Recommendations

The AAFP highlighted the following key recommendations from the 2018 ACC/AHA guideline:

Patients with LDL cholesterol greater than or equal to 190 mg/dL or triglycerides greater than or equal to 500 mg/dL should be evaluated for secondary causes of hyperlipidemia.
A heart-healthy lifestyle should be emphasized for all individuals; lifestyle therapy should be the primary intervention for patients with metabolic syndrome.
Adults 21 and older with a primary LDL cholesterol level greater than or equal to 190 mg/dL should be treated with high-intensity statin therapy unless contraindicated.
Adults ages 40-75 who have an LDL cholesterol level of 70-189 mg/dL without clinical ASCVD or diabetes and an estimated 10-year ASCVD risk of 7.5 percent or greater should be treated with moderate- to high-intensity statin therapy.
Adults ages 40-75 with an LDL cholesterol level of 70-189 mg/dL without clinical ASCVD or diabetes and an estimated 10-year ASCVD risk between 5 percent and 7.4 percent may consider moderate-intensity statin therapy if additional risk factors are present; the decision to treat should include a risk-benefit discussion between the patient and clinician.
Adults ages 40-75 with diabetes and an LDL cholesterol level of 70-189 mg/dL should be treated with moderate-intensity statin therapy.
Patients 75 and younger who have clinical ASCVD should be treated with high-intensity statin therapy unless contraindicated.
In adults at very high risk for ASCVD (e.g., those with a history of multiple major ASCVD events or one major ASCVD event and multiple high-risk conditions), adding a non-statin may be considered at an LDL cholesterol threshold of 70 mg/dL.

Stevermer noted that the ACC/AHA guideline's recommendation to start statin therapy in patients ages 40-75 who have an LDL cholesterol level of 70-189 mg/dL without clinical ASCVD or diabetes and an estimated 10-year ASCVD risk of 7.5 percent or greater differs from the USPSTF's recommendation for these patients.

The USPSTF uses a 10 percent threshold for 10-year ASCVD risk as the point at which to start statins, and then only in patients who have an additional risk factor, such as hypertension or smoking, he said.

Stevermer said he thinks family physicians can be particularly helpful in managing patients who don't tolerate statins well. This is especially true in patients with ASCVD, where statins can have an important preventive role, he added.

"Using our therapeutic relationship, we can identify those patients who have the most to gain from lipid therapy, and then work with them to find a therapy they can tolerate, with the potential of an important reduction in heart attack and stroke," Stevermer said.

Final Thoughts

Stevermer said the ACC/AHA guideline discusses the evidence supporting use of the new proprotein convertase subtilisin/kexin type 9 (PCSK-9) inhibitors and their limited role in lipid therapy. PCSK-9 inhibitors primarily target people with severe or poorly controlled lipid disease.

"The guideline presents a limited role for these expensive medications and identifies their relatively poor cost value," he said.

The guideline also calls for additional research that Stevermer said would benefit practicing family physicians, especially that addressing better identification of patients' 10-year and lifetime risks for CVD.

"Having a more accurate assessment, framed in terms the patient prefers, would certainly assist in discussions around lipid therapy," he concluded.