Disorders of Aging: April 2019

Cholesterol Management Guidelines Call For Personalized Risk Assessments

November 10, 2018 (The Washington Post) – Leading heart experts’ newest cholesterol management guidelines call on doctors to tailor treatment to more personalized risk assessments of each patient and recommend the use of two new kinds of drugs for those at the greatest danger of disease.

The recommendations build on and address criticism of guidelines issued in 2013 that fundamentally altered the way health-care providers determine a patient’s risk of heart attack and cardiovascular disease. In that watershed document, the experts told doctors to stop trying to lower patients’ cholesterol numbers to specific targets and instead follow an overall matrix that attempts to predict their future risk of problems.

The latest guidelines give clinicians a better idea of how to do that via treatment categories that vary depending on cholesterol scores and, if necessary, other tests. The 121-page document was unveiled at the American Heart Association’s 2018 Scientific Sessions in Chicago and published in the Journal of the American College of Cardiology and the heart association’s journal, Circulation.

“We essentially are endorsing and expanding the scope of the risk discussion,” said Neil J. Stone, vice chairman of the committee that wrote the guidelines and a cardiology professor at Northwestern University’s Feinberg School of Medicine.

For example, the guidelines recommend “high-intensity” statin therapy for people under the age of 75 who are determined to have atherosclerotic cardiovascular disease, with the goal of reducing their low-density lipoproteins (LDL), or “bad,” cholesterol by 50 percent. In people aged 40 to 75 with diabetes, “moderate-intensity” statin therapy is indicated regardless of the patient’s 10-year risk of disease, according to another recommendation.

Heart disease is the leading killer of Americans. Nearly a third of all U.S. adults have high LDL levels, a major cause of fatty deposits in arteries that lead to heart attacks, strokes and other cardiovascular problems.

The recommendations reaffirm the guiding principles of heart health that “lower is better” when it comes to LDLs, and that people should try to achieve that first by living a healthy lifestyle, starting in childhood. That includes diet and exercise, controlling blood pressure and avoiding smoking, among other measures.

When those steps aren’t sufficient, the guidelines again endorse statins as the cornerstone of preventive treatment for people at risk of disease. About 43 million people in the United States take statins to lower their LDL levels. The drugs are credited with reducing the risk of heart attacks and strokes.

Two drugs have been developed since the last guidelines were issued in 2013, and the panel endorsed their use in cases when statins are not sufficient. For people who have suffered a heart attack or have numerous high-risk conditions, experts suggest adding ezetemibe. The drug, which is marketed as Zetia but is also available in generic form, decreases the amount of cholesterol absorbed in the small intestine.

In some cases, experts also recommend the use of PCSK9 inhibitors, powerful drugs approved by the Food and Drug Administration in 2015 that block a substance that hinders the liver’s ability to remove LDLs from the blood. The drugs, used mainly to treat an inherited disorder that causes very early heart attacks, are enormously expensive, and the panel offered physicians a way to assess their value.

Parag Joshi, an assistant professor of medicine at the University of Texas Southwestern Medical Center in Dallas, who conducts research in preventive cardiology, said the guidelines combine the old emphasis on LDL scores with the approach outlined in 2013. The move away from LDL scores was loudly criticized by some clinicians when the 2013 recommendations were issued.

Joshi said that in the intervening five years research has shown “really high quality evidence that we can go for [LDL scores of] lower than 70 and do it with these [newer] medicines.”

The committee estimated PCSK9 inhibitors cost more than $150,000 for every good year of life added. Amgen, the drug company that makes the PCSK9 inhibitor Repatha, cut its list price in October to $5,850 per year to make it more affordable, a spokeswoman said.

When doctors have a difficult time deciding how to treat patients, the committee suggests coronary artery calcium tests can be helpful in determining how much plaque has built up on the walls of certain blood vessels. They raised the prospect of beginning cholesterol testing much earlier in life, to identify children at risk of developing heart disease.

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