As new scientifically grounded evidence is developed and validated, clinical, scientific, and policy experts representing key stakeholders gather every several years to review and revise the recommendations that guide how clinicians around the world assess and manage patients with blood fat abnormalities that increase risk of major adverse cardiovascular events.
One in three deaths in the U.S. are cardiovascular. In March, the most recent iteration was published, replacing the last version released in 2018, and I will review the salient statements from the 123-page document. These have been endorsed by the American College of Cardiology, the American Heart Association, and nine other medical organizations.
Of course, one can choose to ignore these recommendations and follow one’s favorite political ideologue or influencer who has something to sell you. If that’s what one chooses, by all means, do so. Darwinian forces will sort this all out. And if you don’t believe Darwin, then even better.
For those who believe in following the best evidence with the most credibility, please continue.
Given the word count limit of which my editor always reminds me, let’s just focus on the main four points.
First, screen for blood fat abnormalities earlier. If there’s a family history of significant and especially premature cardiovascular disease, one can screen a child around 9-11 years of age since some genetically determined lipid profiles can be established by that time, including lipoprotein(a) of which I have written about previously. Early detection gives one the option of early intervention, even if just with lifestyle choices until old enough to consider medications.
Second, check regularly. Puberty may produce some changes, so another panel at 19 years of age and about every five years subsequently. There is a risk calculator called PREVENT-ASCVD that can estimate lifelong cardiovascular risk which one can check yourself, or better, discuss with one’s primary care clinician. Data from many tens of thousands of patients informed the development of this risk assessment tool, which will be refined as more knowledge is generated.
Third, aim for lower LDL-cholesterol, aka bad cholesterol, levels. What the target LDL-C level should be will depend on one’s risk category per the PREVENT-ASCVD calculated risk and one’s baseline lipid levels and concomitant risk factors. For example, if one’s risk for a cardiovascular event is relatively low over the next 10 years, say less than 10%, then the target LDL-C is less than 100 mg/dL. However, if one’s calculated risk is greater than 10%, or one has the genetic form of elevated cholesterol called familial hypercholesterolemia, or has diabetes, high blood pressure, obesity, kidney disease, or coronary artery calcium scores of 100 units or more, then the target LDL-C should be less than 70 mg/dL. And if one has established cardiovascular disease, such as a heart attack, bypass surgery, vascular stents or angioplasty, stroke, or peripheral arterial disease, then the goal LDL-C is less than 55 mg/dL.
Depending on where your genetics and lifestyle set your baseline LDL-cholesterol level, the more stringently low LDL-C recommendations are not going to be achievable by diet and exercise alone. If the baseline LDL-C is 160 mg/dL or greater, medications may be considered under the supervision of one’s clinician to prescribe and monitor the benefit and watch for any adverse effects. Age to initiate therapy, assuming one does not have the familial form of hypercholesterolemia, is now 30 years, down from the prior 40 years of age. Diet and exercise are the lifestyle changes to try first.
The new dietary recommendations from Robert F. Kennedy Jr.’s HHS that increase saturated fat content may not help lower the LDL-C. Getting a coronary artery calcium score may help inform the decision to start medications if one is a male over 40 years or women over 45 years of age. Statins remain the medication mainstay with the best hard evidence of benefit, but there are several nonstatin options that can be used alone or in combination with statins to achieve target LDL-C levels.
Indeed, an important study completed too late to be included in the new guidelines used a nonstatin LDL-C lowering agent in elevated cholesterol patients on statins who had not had any cardiovascular event to demonstrate a significant reduction in the occurrence of the first cardiovascular event with the incremental lowering of LDL-C. This important study may influence future amendments to these guidelines, especially as generic and oral versions of this drug class become available.
A couple of other points here. It is an extremely rare patient whose LDL-C cannot be controlled with the therapeutic arsenal we now have available, with potentially even better agents in the research pipeline. Many of these currently available agents are generic, so are affordable and covered by most insurance plans. Secondly, there is no such thing as too low a cholesterol level. Your body makes the cholesterol it needs, and cardiovascular risk continues to drop as the LDL-C cholesterol level does. I’ve been doing lipid management for over 50 years, and participated in the development of this field as a clinical investigator for those five decades.
Lipoprotein(a) is an increasingly recognized and soon to be treatable potent risk factor for aggressive cardiovascular disease. New lipid management therapies are constantly being developed and we are actively engaged with the development of several of these novel medications at our research site.
And fourth, treat longer. Anytime a new lipid intervention is initiated, check the results after about 4-12 weeks, and then every 6-12 months thereafter or sooner if any adverse events are suspected. The longer one is on effective and well-tolerated therapy, the greater the benefit. This means even initiating and continuing lipid therapy into ages 80 and beyond, though closer monitoring may be prudent due to conflation of symptoms.
So, in one sentence, look sooner, start earlier, go lower, for longer … it’s better. Talk to your doctor.
Irving Kent Loh, M.D., is a preventive cardiologist and the director of the Ventura Heart Institute in Thousand Oaks. Email him at drloh@venturaheart.com.
This article originally appeared on Ventura County Star: Breaking down the new lipid guidelines | Dr. Loh
Reporting by Dr. Irving Kent Loh, Second Opinion / Ventura County Star
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