There are general guidelines in life and thankfully there are guidelines to help you live a better life by taking better care of yourself. The latest Guideline on the Management of Blood Cholesterol may not have made the New York Times Best Sellers list. However, it definitely has the attention of the medical community — your cardiologist or primary care physician — and it should have your attention too if you have high blood cholesterol.
Your LDL or "bad" cholesterol accumulates in your arteries, narrowing them and eventually causing the development of atherosclerosis. It's generally felt that the optimal level for LDL is less than 100 mg/dL (milligrams per deciliter) if you're healthy. Hopefully, you're already taking steps to eat healthy and get enough physical activity — things you definitely can control.
Published in the journal Circulation in November 2018, the guideline, an update of the 2013 version, was a joint effort by members of no less than 11 respected medical associations, starting with the American College of Cardiology and American Heart Association Task Force.
"This was written for the United States," said the comprehensive paper's second author among 24 total authors, Neil J. Stone, M.D. FACC, FAHA, who spoke to HealthCentral in a telephone interview. He is professor of medicine (cardiology) and preventive medicine at Northwestern Medicine and the Feinberg School of Medicine in Chicago.
"In this country, one in three people will die of a heart attack or stroke, and six out of 10 will suffer a heart attack or stroke before they die. The guideline makes recommendations over the whole life course. It also personalizes risk decisions — including whether or not you have already had a heart attack or stroke, or are primarily trying to prevent one in the future."
Here's what Dr. Stone thinks really stands out among these most current, practical guidelines, designed to reduce atherosclerotic cardiovascular disease risk:
1) If at first…
"The guidelines are specifically focused on high-risk people who stand to gain the most benefit," he says. "We don't want to recommend high-intensity treatment to the average person."
For those people, the LDL-C threshold is set at 70 mg/dL. For those who have had a heart attack or stroke, and are at risk for another one, and whose LDL (bad) cholesterol levels can't be sufficiently controlled by statins, even at the maximal dose, the new guideline suggests adding other cholesterol-lowering agents. If levels are still above 70 mg/dL, these include ezetimibe (Zetia) and if that doesn't lower the number, a PCSK9 inhibitor such as evolocumab (Repatha).
2) Not so 'fasting' anymore
If you dread having to fast before your blood work — because, well, you need that Frappuccino to get revved up — relief may be here. "We emphasize that a non-fasting lipids test may be fine for screening," says Dr. Stone. "Increasing data show if you've eaten lightly in the morning, and you see your doctor in the afternoon, you don't have to return for a fasting test for the lipid panel to be interpreted very well. I'm not saying you should have a hamburger, fries and a shake, however!"
3) The risk score still matters
You and your doctor have probably talked about your risk score: a 10-year risk calculation. It asks your age, gender, race, cholesterol numbers, blood pressure and whether it's treated, your diabetes status and whether you're a smoker. For people age 40 to 75, this can still help determine whether you should be recommended for a statin.
For those around which uncertainty exists, the guidelines also pay attention to coronary artery calcium score, a kind of tiebreaker.
4) Revised for more age groups
The 2013 guideline did not pertain to people over 75 or younger than 40 who have risk factors, because as the American Heart Association says, they "are the most likely to need medicine." Now they do apply.
5) It comes back to you
That personalization mentioned earlier is a defining marker of the new guideline. In other words, your medical history and risk factors aren't like anyone else's and maybe, just maybe, you don't need a statin. "Patient preference has to be considered," says Dr. Stone. "That makes the clinician-patient risk discussion an important factor. We want informed patients to decide, using shared decision-making, if taking a statin makes sense for them, including considering side effects.
We want the guideline to make sense — they're not 'automatic' — and they actually require a conversation between doctor and patient which yields a better understanding of what risk is, and what the potential for benefit is. We want them to improve the health of patients across the United States."
6) Guidelines' 'prognosis' looks good
It takes a few years for guidelines to be well tested and understood by the medical community, "and to truly reach most doctors effectively," Dr. Stone says. "We've already heard very good feedback."
'A second opinion'
He's someone who's already using the new guideline and who shared his feedback about the new guideline via email with HealthCentral. Clinical cardiologist Tamer Sallam, M.D., is frequently consulted about cholesterol problems. He's is an assistant professor of medicine at the David Geffen School of Medicine at UCLA and a clinical cardiologist at Ronald Reagan UCLA Medical Center, and he reflects on the new directives.
"The idea that providers should emphasize healthy lifestyle choices is not necessarily new but what is strongly highlighted in the new guideline is that we need to engage patients early and throughout their lifespan," Dr. Sallam says. "Heart disease can progress in the second or third decade of life so it makes sense that we need to stress heart-healthy habits and assess risk factors for all young adults starting at the age of 20."
He also knows from vast experience that statins work well for some and not so well for others — we're all different. "There is no such thing as a one-size-fits-all approach when it comes to statin therapy," he says. "Statins have demonstrated efficacy for many patient groups but treatment with a statin is not for everyone. The latest guideline stresses the importance of a patient-provider discussion before initiating treatment with a statin to prevent atherosclerotic cardiovascular disease. Factors to consider when weighing the risks and benefits of statin therapy include potential benefits of treatment, possible side effects, costs, as well as patient preferences and beliefs."
He applauds the new guidelines' "specific LDL treatment goals for patients at high risk for heart disease and recommendations on using non-statin cholesterol-lowering medications."
Our understanding of cholesterol and how to better control it advances significantly with each guideline, giving physicians and their patients even more to work with — together.