The new ACC/AHA guidelines on the treatment of dyslipidemia: cons.

Abstract

The new 2013 ACC/AHA and the 2011 ESC/EAS:overviewIn November 2013, the American College of Cardiology(ACC) and the American Heart Association (AHA) pub-lished a set of guidelines on the control of blood cholesterolto reduce atherosclerotic cardiovascular disease (ASCVD)risk in adults [1]. This latest set of ACC/AHA guidelinesfocuses specifically on cholesterol management and onstatin therapy rather than other forms of dyslipidemias oralternative therapeutic approaches (as in the ESC/EAS2011 guidelines) and recognizes that more intensive statintreatment is superior to less intensive treatment for manypatients. However, the shift away from the previous ATP-III set of guidelines published a decade ago [2], whichprovided a comprehensive guide to lipid management, hascreated controversy and confusion about the relative meritsof these new ACC/AHA guidelines when compared withexisting guidelines such as the ESC/EAS guidelines for‘the management of dyslipidemias [3]’. Whereas somehave embraced the new ACC/AHA guidelines as ‘a step inthe right direction’ for reasons of simplifying patient care,others disagree; certainly sweeping endorsements areoverly optimistic and warrant greater caution.SimilaritiesBoth ESC/EAS and the new ACC/AHA guidelinesemphasize the importance of LDL cholesterol (LDL-C)reduction in cardiovascular prevention, in both primary andsecondary CVD prevention. Both the European and theACC/AHA guidelines highlight the importance of riskstratification. Finally, they share a similar, althoughsomewhat different, view of four major groups of patientsfor whom statin therapy have the greatest chance of pre-venting CV events: (1) patients on secondary CVD pre-vention, (2) patients with remarkable elevation of LDL-C(potential familial forms of hypercholesterolemia), (3)patients with diabetes, and (4) those on primary CVDprevention at high risk of events.DifferencesAlthough the aim of both guidelines is to use statins tolower LDL-C, it is here that the first significant shiftoccurs, because the new ACC/AHA guidelines discard theuse of lipid targets to guide physicians and patients, citingan absence of RCT (randomized controlled trials) evidencethat support such a strategy. Therefore, the ACC/AHAguidelines aim at the intensity of statin therapy (high- ormoderate-intensity) rather than LDL-C targets for patientsat risk of ASCVD. Furthermore, in the ACC/AHA guide-lines a new risk estimation model for evaluating the totalCVD risk (pool cohorts equations) has been developed:from the available analyses, it is at least controversial howthis new model would work in relation to the EuropeanSCORE model. Last but not least, it should be consideredthat the ESC/EAS guidelines have a broader approach ondyslipidemias in general, while the ACC/AHA guidelinesare focused on cholesterol and statin treatment in cardio-vascular prevention. Therefore, in the ESC/EAS guide-lines, special groups of patients, such as individuals withfamilial hypercholesterolemia, combined hyperlipidaemiaand diabetes, and stroke are discussed more in detail.