Clinical Guidelines | 4 March 2014

Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Disease Risk in Adults: Synopsis of the 2013 American College of Cardiology/American Heart Association Cholesterol Guideline
Neil J. Stone, MD; Jennifer G. Robinson, MD, MPH; Alice H. Lichtenstein, ScD; David C. Goff Jr., MD, PhD; Donald M. Lloyd-Jones, MD, ScM; Sidney C. Smith Jr., MD; Conrad Blum, MD; J. Sanford Schwartz, MD, for the 2013 ACC/AHA Cholesterol Guideline Panel*

Ann Intern Med. 2014;160(5):339-343. doi:10.7326/M14-0126 This article was published online first at http://www.annals.org on 28 January 2014.
Abstract | Guideline Development Process | Recommendations | Summary | Appendices | References
Description: In November 2013, the American College of Cardiology and American Heart Association (ACC/AHA) released a clinical practice guideline on the treatment of blood cholesterol to reduce cardiovascular risk in adults. This synopsis summarizes the major recommendations.

Methods: In 2008, the National Heart, Lung, and Blood Institute convened the Adult Treatment Panel (ATP) IV to update the 2001 ATP-III cholesterol guidelines using a rigorous process to systematically review randomized, controlled trials (RCTs) and meta-analyses of RCTs that examined cardiovascular outcomes. The panel commissioned independent systematic evidence reviews on low-density lipoprotein cholesterol and non–high-density lipoprotein cholesterol goals in secondary and primary prevention and the effect of lipid drugs on atherosclerotic cardiovascular disease events and adverse effects. In September 2013, the panel’s draft recommendations were transitioned to the ACC/AHA.

Recommendations: This synopsis summarizes key features of the guidelines in 8 areas: lifestyle, groups shown to benefit from statins, statin safety, decision making, estimation of cardiovascular disease risk, intensity of statin therapy, treatment targets, and monitoring of statin therapy.
Summary
Abstract | Guideline Development Process | Recommendations | Summary | Appendices | References
Millions of U.S. adults are at increased ASCVD risk—some because they have had an ASCVD event, others because of ASCVD risk factors. Adherence to healthy lifestyle behaviors, control of blood pressure and diabetes, and avoidance of smoking is recommended for all adults. Statin therapy should be used to reduce ASCVD risk in individuals likely to have a clear net benefit (those with clinical ASCVD) or in primary prevention for adults with LDL-C levels ?190 mg/dL, those aged 40 to 75 years with diabetes, and those with a 10-year ASCVD risk ?7.5% without diabetes. A clinician–patient discussion that considers potential ASCVD risk reduction, adverse effects, and patient preferences is needed to decide whether to initiate statin therapy, especially in lower-risk primary prevention.

Appropriate intensity of statin therapy based on ASCVD risk and potential for adverse effects is recommended rather than focusing on specific LDL-C or non–HDL-C goals. Five of the 7 statins marketed in the United States, including a high-intensity statin, are available as low-cost generics.

The Pooled Risk Equations, which were developed in a geographically diverse sample of African Americans and non-Hispanic whites, identify adults at increased risk for an ASCVD event (including stroke as well as heart disease). They represent important steps forward in the ability to match intensity of preventive treatment to level of ASCVD risk. These risk equations will be reevaluated and revised as additional information becomes available, including research assessing other potentially useful markers of ASCVD risk and data required to develop equations specific to other ethnic groups.

Until heart-healthy lifestyles are adopted throughout the lifespan, the need for preventive measures using evidence-based drug therapy will remain high. As with all clinical guidelines, the 2013 ACC/AHA cholesterol guidelines must be implemented in conjunction with sound clinical judgment. These evidence-based recommendations focus statin treatment on patients likely to obtain the greatest benefit, thereby reducing the ASCVD burden in adults