Statin Guidelines

Should you be taking a statin medication to control cholesterol and reduce your risk of a cardiovascular event? As Rick and I discuss on PodMed this week, according to new guidelines published in Circulation somewhat euphemistically called '2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults," many, many more people than are currently taking these medications should be. And I say 'euphemistically called' because we also agree with our colleague Michael Blaha, who quips that these should really be called statin guidelines as no other medication even receives a nod with regard to cholesterol management.  So what did these guidelines assess and what do they say?

The panel conducted a review of all the randomized controlled trials and meta-analyses of same related to atherosclerotic cardiovascular disease outcomes from January 1, 1995 through December 1, 2009. Studies were assessed and rated and data synthesized into evidence statements rated from strong to no evidence.  Additional evidence from more recent studies was also included in the discussion.  Here's what is new:

There are four main groups that would most likely benefit from statin therapy: folks with clinically evident atherosclerotic cardiovascular disease, those with an LDL greater than or equal to 190 mg/dl, people with diabetes aged 40-75 years and an LDL of 70-189, and finally, those who don't fall into the second or third groups, above, but whose 10 year risk of a cardiovascular event, including stroke, is greater than or equal to 7.5%.  If all these groups were brought under the statin umbrella, estimates are an increase of up to 100% in those currently taking the drugs.  Statin nation, anyone?  As Rick opines in the podcast, the fourth group, above, would rein in older folks with otherwise good health and nonexistent or controlled risk factors simply because their age places them in a group at risk for cardiovascular events in the next ten years.  Might be a bit of a tough sell, methinks.

The guidelines also eliminate the benchmark of LDL cholesterol as a target for therapy, because of the lack of an evidence base!  WOW!  I'll go out on a limb here and speculate that this is going to take quite some time to penetrate the collective consciousness and make sense to many primary care providers, let alone patients themselves.  Rick and I both applaud application of evidence in eliminating LDL measurement except initially, but predict that this change in particular will likely account for hours of education time on the part of clinicians to alleviate public confusion.

Finally, what about the no man's land of people whose risk may be thought of as low to intermediate yet eligible for statin therapy, but who resist? The panel rather dryly states that treatment decisions may be informed by other factors, presumably things like coronary calcium scanning, but isn't recommending same.  For those of us addicted to numbers, though, I wonder how much more utilization of these we're going to see.  In sum, then, Rick believes these guidelines are the first pass, likely to be modified, and then there's the issue of the risk calculator.  But that's another story.

Other topics this week include more studies from the AHA meeting, all published in JAMA.  These include lowering body temperature in the field in those who've had an MI, immediate blood pressure lowering in stroke, and mechanical versus manual compressions in CPR.  Until next week, y'all live well.

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Statin Guidelines | jhublogs
November 22, 2013 at 12:10 pm

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