Misinterpretation of cholesterol, risk-assessment guidelines may produce unintended consequences

BOSTON — Misinterpretation of the 2013 American College of Cardiology/American Heart Association guidelines on cholesterol management and CV risk assessment may result in unintended consequences, leading experts here to say that communication and physician education is key.

At the Cardiometabolic Health Congress, Neil J. Stone, MD, MACP, FAHA, FACC, chair of the working group that wrote the ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults, presented an overview of the guidelines and the new recommendations within. In a departure from previous guidelines, the 2013 guidelines lack endorsement of treating to LDL target levels and adopted a 10-year risk estimator to predict CVD risk for primary prevention in individuals with LDL <190 mg/dL.

Neil J. Stone

Rationale for changes

Stone said the risk estimator was designed to determine who qualifies for a clinician-patient discussion that examines risk factor management and adherence to lifestyle; reviews the potential for benefit, adverse effects and drug-drug interactions with statins; and elicits an informed patient preference.

Additional factors, such as family history of premature atherosclerotic CVD; high-sensitivity C-reactive protein ≥2 mg/L; coronary artery calcium score ≥300 Agatston units or ≥75th age, sex and race percentile; ankle-brachial index <0.9; or LDL ≥160 mg/dL can be used to inform the discussion if a risk decision is uncertain, Stone said.

The guidelines also include a lifetime risk estimator for individuals aged 20 years to 59 years expressly designed to enhance lifestyle discussions to reduce risk factors, he said.

Since the release, the guidelines have been intensely discussed and debated. Here, attendees of the Cardiometabolic Health Congress weighed in on the guidelines, with several audience members pointing out that much confusion still remains nearly 1 year after their publication.

Unintended consequences

Among the consequences mentioned by commenters at the Cardiometabolic Health Congress:

Many doctors are defaulting to prescribing statins for patients who may be at risk for atherosclerotic CVD without first having the clinician-patient risk discussion recommended in the cholesterol guideline.
Some doctors are no longer ordering cholesterol tests for many of their patients because treating to LDL target levels is not endorsed in the guideline, despite the guideline stating that tests should continue to be ordered so that doctors can review adequacy of LDL lowering and monitor compliance with therapy.
According to some audience members, some insurance companies are no longer reimbursing for non-statin cholesterol-lowering drugs because the guideline strongly recommended statins over other drug therapies, due to available evidence of beneficial clinical outcomes.

Stone said, however, that the guidelines clearly state that in high-risk patients who have a less-than-anticipated response to statins, who are unable to tolerate a less-than-recommended intensity of a statin or who are completely statin intolerant, clinicians may consider nonstatin cholesterol-lowering drug therapy. He said high-risk individuals include those with atherosclerotic CVD, those with LDL ≥190 mg/dL, and those aged 40 years to 75 years with diabetes.

Stone, the Bonow professor of medicine at Northwestern University Feinberg School of Medicine, acknowledged that the guideline working group has written editorials to the American Academy of Family Physicians (McBride P. Am Fam Physician, 2014;90:212-216), the Annals of Internal Medicine (Stone NJ. Ann Intern Med. 2014;160:339-343) and other bodies to address these issues.

“We have tried very hard to deal with some of the misinformation. … We are going to keep trying,” Stone said.

Because of such misinterpretations, increased efforts should be made to educate community physicians about what the guidelines actually say, audience members said. – by Erik Swain

For more information:

Stone NJ. CVD Prevention Guidelines Update: Clinical Impact and Current Controversies. Presented at: Cardiometabolic Health Congress; Oct. 22-25, 2014; Boston.

Disclosure: Stone reports no relevant financial disclosures.