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Are the new ACC/AHA Cholesterol Treatment Guidelines a step forward or a step backward?
The main concern about the new ACC/AHA treatment guidelines compared to the NCEP is the sudden departure from treat-to-goal, lower LDL cholesterol is better and risk-based treatment approaches. The reason given was randomized clinical statin trials used fixed doses of cholesterol-lowering drugs to reduce cardiovascular events. Why did the pharmaceutical companies use fixed doses? All the randomized statin clinical trials from the 4S in 1994 to the JUPITER in 2008 were developed by pharmaceutical companies to help generate more revenues for their shareholders, not to develop ACC/AHA treatment guidelines. The NCEP ATP III expert panel analyzed the same dataset from randomized statin clinical trials but did not conclude that they should recommend fixed dosing just like what the pharmaceutical companies did with their trials. Both panels are experts but the approaches they took are so different that they can't be both correct. For the sake of greater transparency, both the ACC and AHA should fully disclosed their financial benefits, including the amount, from pharmaceutical companies and device manufacturers and state them clearly in the preamble.
Please visit www.CholesterolClinic.com for more discussion with slides. Also watch this short video at http://www.cholesterolclinic.net/contact/the-two-sides-of-aggressive/.
In 2007, when the COURAGE trial came out, as a board member, I proposed that the NLA should be the voice of CVD prevention since all our activities are about or related to prevention. There is no other national organization like us. In 2007, it was hard to find anything on prevention in the ACC and AHA journals - the contents are all about stents, heart bypass, heart failure, etc. These are all late complications of CVD that we at NLA are trying to prevent in our own practices. We are now in a different time - healthcare is undergoing a radical transformation. It is all about improving patient outcomes while reducing healthcare cost. That is what we are all about. It is time to kill the goose that lays the golden egg. With Affordable Care Act and Million Hearts Initiative, this is the appropriate time for the NLA to take the opportunity to become the voice of CVD prevention for the country.
Rolando L. deGoma, MD, FACC, FNLA
This page was last updated: Dec 08, 2013
Residual Risk
For those clinicians who are targeting secondary lipoprotein measurements, the new ACC/AHA guidelines ignore the utility of combination therapy or variable statin dosing which might be necessary for individualized management. A fixed dose statin treatment, which seemingly leads to substantial outcome improvement, does not address the risk that may be missed as described in Dr. deGoma's excellent video: For most patients at risk for cardiovascular and cerebrovascular events, there is not at high level of stenosis and a 50% reduction in LDL by high dose statin treatment, will reverse some of the atherosclerosis, but may miss patients with residual lipoprotein abnormalities.
I applaud Dr. deGoma's observations regarding the potential conflict that arises when drawing broad population based treatment guidelines from industry sponsored studies.
Spencer Kroll MD PhD FNLA