Updated: Jan 8, 2021
*This is a reprint of a post from 7 years ago*
In November 2013 the American Heart Association and the American College of Cardiology released new guidelines for prevention of cardiovascular disease. These have gotten quite a bit of media attention and were met with varying responses from the health care community. I found the reports in the media a bit confusing, so I wanted to offer a clear summary for my community.
Interestingly, it proved very difficult to access the actual document containing the guidelines. All the media articles linked to the American Hearth Association website which has a link to a very long, scientific paper about the CREATION of the guidelines but did not provide the guidelines themselves. In order to access the actual guidelines, you had to find a footnoted link in the middle of the creation document that took you to another very long paper in scientific language that discussed the actual guidelines and the rationale behind them.
What are the guidelines for?
Guidelines are primarily intended as a guide to prescribing statin drugs. They are NOT intended to be a comprehensive guide to diagnosis, treatment or prevention of cardiovascular disease or atherosclerosis (CVD, AS). According to the paper:
“these guidelines were never intended to be a comprehensive approach to lipid management for purposes other than ASCVD risk reduction.”
The guidelines are intended to help prescribers determine which patients are at high enough risk for CVD and cardiovascular events (stroke, heart attack) that the benefit of taking statins, outweighs the risk of side effects. The guidelines are also to help prescribers know what dose of statins to use with these higher risk groups.
Why did they make new guidelines?
Past guidelines were based on older research using primarily white males as subjects. This meant that the guidelines were not necessarily as accurate for women, African Americans, Hispanics or Asians. The earlier guidelines also used a “treat to target” structure, using LDL as a benchmark, working on the assumption that lower LDL was better. The intent of the update was to have guidelines that were more relevant to women, and non-whites, as well as reviewing the past assumption of “treat to target” (treat until is LDL below 100). The New Guidelines were made by reviewing new research up through 2011 (nothing past 2011 was used).
What did the research say?
No more "treat to target". Overall, they did not find research support for using statins to lower LDL’s to previous target levels. Yes, you read that right. They found that using statins to lower LDL’s below 100 did NOT reduce risk of CVD. This recommendation from previous years has been dropped. They no longer recommend “treat to target”. This is a big deal.
Otherwise they used research on women and African Americans to make slight changes in the mathematical calculations done to assess 10 year risk of having a non-fatal cardiovascular event. Please note, they still do not have clear guidelines for Asians, Hispanics or Native Americans. They acknowledged that these groups have significantly different risk ratios than whites, and that the calculator results for these groups should be considered in this context.
Studies also found that there was no benefit to using adjunct therapies (adding niacin to statins) in order to further lower LDL, HDL, cholesterol, or triglycerides. They also did not find benefit to use of statins beyond the age of 75.
What are the actual guidelines?
Here is a link to the actual guideline document:
My summary of the Guidelines
Diet and lifestyle are recommended as “critical component” and “background” therapy either before or in conjunction with statin therapy.
These are defined as a heart healthy diet, regular exercise, avoidance of tobacco and maintaining healthy body weight.
It is important to note that this was their number one recommendation. The authors were clear that diet and lifestyle could not be ignored, even when statins were being prescribed.
As a holistic health advocate, I am a big fan of this recommendation and am really happy to see it listed first!
The authors identified 4 high risk groups that should benefit from statins, and for whom the benefit of statins should outweigh the risk of taking statins.
Patients who already have ASCVD (atherosclerotic cardiovascular disease)
LDL over 190 (this is a radical change from previous recommendations for LDL target below 100 or even below 60!)
Adults with diabetes (type 1 or 2) AND with LDL above 70
Total ASCVD 10 year risk over 7.5% (based on the calculator- discussed below)
There is now a digital algorithm available on several medical sites that leads prescribers through identifying these groups and makes suggestions for stain dosing. Examples:
Difference between the old calculators and the 2013 update
The previous risk calculator was based on the Framingham studies. It took into consideration: age, gender, HDL, total cholesterol, systolic blood pressure, if you are on blood pressure reducing medicine, and smoking status.
The new calculator is very similar. It has the addition of considering race (white or African American), as well as diabetes status.
The math behind the calculator does vary as it is supposed to take new data into consideration.
The calculator is to be used for white & black adults WITHOUT current ASCVD. It can be used for other races, but is less accurate.
My colleagues and I did some experimenting with the new calculator. We found that the 10 year risk scores seemed accurate for each of us. The calculator also provides a “lifetime risk” score, which seemed to be completely inaccurate (it was high on all of us, even when we had no risk factors and less than 1% 10 year risk). These artificially high “lifetime risk” scores oddly went down when we added risk factors (such as smoking, or diabetes). The good news here is that there are NO recommendations for prescribing statins based on these “lifetime risk” numbers. All recommendations are based on the 10 year risk numbers, which appear to us to be reasonably accurate.
Overall, the new recommendations seem to me to be progress in the right direction. I am happy to see that diet and lifestyle are stressed, even in a guide that is intended for prescribing statins. I am also happy that the “treat to target” to lower LDL’s below normal levels has been dropped. This gives me hope that we will see fewer patients on unnecessary statins, especially for those patients who are otherwise healthy, eat a healthy diet, exercise and don’t smoke.