The new ACCF/AHA guidelines on the treatment of dyslipidemia: pros.

Abstract

The new 2013 ACC/AHA Guidelines in hypercholesterolemic adults [1] have spurred major debates in the medical community as well as in the lay press. Compared with the previous report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) [2] and with the 2011 ESC Guidelines in the same area [3], these guidelines have identified four major groups of patients for whom cholesterol-lowering HMG-CoA reductase inhibitors, or statins, have the greatest chance of preventing stroke and heart attacks, and suggest treating them from the very beginning with a moderatehigh-intensity dose. The guidelines also largely emphasize the importance of adopting a heart-healthy lifestyle to prevent and control high blood cholesterol. These guidelines represent a departure from previous documents because they do not focus on specific target levels of low-density lipoprotein cholesterol, commonly known as low-density lipoprotein (LDL), or ‘‘bad’’ cholesterol, although the definition of optimal LDL cholesterol has not changed. Instead, they focus on defining groups for whom LDL lowering is proven to be most beneficial. The guidelines focus only on the use of statins, after a detailed review of other cholesterol-lowering drugs. Statins were chosen because their use has resulted in the greatest benefit and the lowest rates of safety issues. No other cholesterollowering drug is as effective as statins, although there is a role for other cholesterol-lowering drugs, for example, in patients who suffer side effects from statins. The guidelines emphasize that, although other strategies for using drug therapy to reduce atherosclerotic cardiovascular disease (ASCVD) events have been advocated, including treat-to-cholesterol target, lowest is best, and risk-based treatment approaches, only one approach has been de facto evaluated in multiple randomized clinical trials (RCTs)—the use of fixed doses of cholesterol-lowering drugs to reduce ASCVD risk. Because the overwhelming body of evidence comes from statin RCTs, the Expert Panel appropriately focused on these statin RCTs to develop evidence-based guidelines for the reduction of ASCVD risk.