The Influence of Lipid Guidelines on Real-World Practice Patterns

Zachary T. Bloomgarden, MD, MACE: In 2013, amidst a certain amount of controversy, the American Heart Association and the American College of Cardiology decided to make a major change in the way the lipid guidelines were put forward. They would no longer recommend [that patients receive] treatment to [reach] specific [goal] levels of LDL (low-density lipoprotein) cholesterol—[for example], under 100 in individuals who were high risk but did not have evidence of atherosclerotic cardiovascular disease, and under 70 in individuals who had evidence of ASCVD (atherosclerotic cardiovascular disease). Instead, they said [that] any individual who has evidence of ASCVD or certain other criteria should be treated with high doses of high-potency statins, period. Any individual who has moderate risk, but does not have ASCVD, should be treated with lower doses of these statins.

Other cholesterol-lowering drugs were specifically excluded from this, and many commentators observed that this is a peculiar misuse of evidence-based medicine. So, while it is true that the studies all compared higher doses of statins with lower doses, or higher doses or lower doses with those statins, it’s a far cry from saying that it implies that the only therapeutic implication of the trials is that the choice should be between high-dose, lower-dose, or no statin.

And so, many people strongly disagree with those guidelines. Nevertheless, they’re much easier for clinicians to apply. The clinician can say to the patient, “Here’s what you need. You have evidence of ASCVD. You had a stent. You need to take 40 or 80 mg of atorvastatin, or 20 or 40 mg of rosuvastatin.” Or, “You didn’t have an event, but you have diabetes. You need to take 10 mg of atorvastatin (or the like).”

So there are certain desirable aspects of it, although I personally find the notion of not using specific lipid goals to be one which really does take away one of the crucial dimensions that clinicians would want to use in ascertaining the response to treatment.Zachary T. Bloomgarden, MD, MACE: In 2013, amidst a certain amount of controversy, the American Heart Association and the American College of Cardiology decided to make a major change in the way the lipid guidelines were put forward. They would no longer recommend [that patients receive] treatment to [reach] specific [goal] levels of LDL (low-density lipoprotein) cholesterol—[for example], under 100 in individuals who were high risk but did not have evidence of atherosclerotic cardiovascular disease, and under 70 in individuals who had evidence of ASCVD (atherosclerotic cardiovascular disease). Instead, they said [that] any individual who has evidence of ASCVD or certain other criteria should be treated with high doses of high-potency statins, period. Any individual who has moderate risk, but does not have ASCVD, should be treated with lower doses of these statins.

Other cholesterol-lowering drugs were specifically excluded from this, and many commentators observed that this is a peculiar misuse of evidence-based medicine. So, while it is true that the studies all compared higher doses of statins with lower doses, or higher doses or lower doses with those statins, it’s a far cry from saying that it implies that the only therapeutic implication of the trials is that the choice should be between high-dose, lower-dose, or no statin.

And so, many people strongly disagree with those guidelines. Nevertheless, they’re much easier for clinicians to apply. The clinician can say to the patient, “Here’s what you need. You have evidence of ASCVD. You had a stent. You need to take 40 or 80 mg of atorvastatin, or 20 or 40 mg of rosuvastatin.” Or, “You didn’t have an event, but you have diabetes. You need to take 10 mg of atorvastatin (or the like).”

So there are certain desirable aspects of it, although I personally find the notion of not using specific lipid goals to be one which really does take away one of the crucial dimensions that clinicians would want to use in ascertaining the response to treatment.