Statin use urged for 33 million Americans

Statin therapy is now recommended for approximately 33 million more Americans who don’t have cardiovascular disease (CVD), but have an estimated 10-year CV risk of 7.5% or higher. These individuals also have LDL cholesterol between 70 mg/dL and 189 mg/dL, according to new guidelines issued Nov. 12 by the American College of Cardiology and the American Heart Association.

The new cholesterol recommendations identify four major groups of adults who could benefit from moderate- to high-intensity statin therapy: patients who are 75 years and younger with clinical CVD, patients with LCL cholesterol of 190 mg/dL or more, patients with type 1 and 2 diabetes who are 40 to 75 years old, and patients who are 40 to 75 years with an estimated 10-year CV risk of 7.5% or more and whose LDL cholesterol is between 70 mg/dL and 189 mg/dL.

“Despite an extensive review, we were unable to find solid evidence to support continued use of specific LDL-C or non-HDL-C treatment targets,” said Neil J. Stone, MD, Bonow Professor of Medicine at Northwestern University Feinberg School of Medicine and chair of the expert panel for the cholesterol guidelines, quoted by the American Pharmacists Association.

This is a major shift from the 2002 cholesterol guideline that recommended statin therapy only for individuals with a 10-year CV risk level above 20%. The old guideline did not take into account the risk for stroke, only the risk for heart disease, according to a American Heart Association report.

“We’ve been undertreating people who need statin therapy in this country,” said AHA volunteer Donald Lloyd-Jones, MD, also a member of the expert panel. “Statins lower cholesterol levels, but what they really target is overall cardiovascular risk.”

In addition to the cholesterol guideline, revised guidelines were released for diet/exercise, obesity, and risk assessment, according to the AHA.

A new lifestyle management guideline for individuals with elevated cholesterol and blood pressure recommends a diet that includes fruits, vegetables, whole grains, low-fat dairy products, poultry, fish, and nuts, but limits consumption of red meats and food/drinks with sugar. A diet that limits sodium to 2,400 mg daily should be considered for patients with hypertension. Exercise should consist of 40 minutes of moderate to vigorous aerobic exercise three to four times per week.

Recommendations for obese patients will help clinicians identify patients who need to lose weight, will match treatment with risk profiles, offer diets for weight loss, lifestyle intervention, and counseling, as well as aid in the selection of candidates for bariatric surgery.

Healthcare providers are advised to measure height and weight in order to calculate body mass index (BMI) during annual visits or more often. Overweight and obese patients are defined by a BMI of >25.0-29.9 kg/m2 or >30 kg/m2, respectively. Waist circumference also should be measured annually or more often in overweight and obese patients.

“Advise adults that the greater the waist circumference, the greater the risk of CVD, type 2 diabetes, and all-cause mortality,” the obesity guideline stated.

Patients should be counseled that lifestyle changes as modest as sustained weight loss of 3% to 5% can produce clinical health benefits in terms of reductions in triglycerides, blood glucose, hemoglobin A1C, and the risk of type 2 diabetes. Losing more weight will reduce blood pressure, improve cholesterol levels, and reduce the need for drugs to control blood pressure, cholesterol, and blood glucose.

Bariatric surgery can be considered in adults with BMI >40 or >35 with obesity-related comorbid conditions who have not responded to behavioral treatment or pharmacotherapy to achieve sufficient weight loss. There is no sufficient evidence to recommend either for or against bariatric surgery for adults with a BMI <35.

“The panel did not choose to deal with various aspects of pharmacotherapy … since at the time the CQs were chosen there was only one approved medication (orlistat) for weight loss,” the expert panel wrote.

The guideline for risk assessment of CVD no longer follows the Framingham 10-year risk score estimates of coronary heart disease. New equations were developed to incorporate sex, race, age, treated/untreated systolic blood pressure level, total, and HDL-cholesterol levels, smoking status, and history of diabetes.