New cardio guidelines change statin use, CVD risk assessment

The American Heart Association (AHA) and American College of Cardiology (ACC) issued 4 new cardiovascular disease prevention guidelines last week on cholesterol treatment, cardiovascular risk assessment, lifestyle management and management of overweight and obesity.

The cholesterol guideline made substantial changes to recommendations about statin use, moving away from specific cholesterol targets and likely increasing the number of patients taking the drugs, according to a press release.

Moderate- or high-intensity statin therapy is recommended for patients who have:

• clinical cardiovascular disease (CVD),
• an LDL cholesterol level of 190 mg/dL or higher,
• type 1 or type 2 diabetes and are between 40 and 75 years of age with an LDL cholesterol level of 70 to 189 mg/dL, or
• an estimated 10-year risk of CVD of 7.5% or higher (as estimated using the Pooled Cohort Equations) and are between 40 and 75 years with an LDL cholesterol level of 70 to 189 mg/dL.

The second guideline introduced a new method for assessing cardiovascular risk that was broadened from current measures (such as the Framingham risk score) to include assessment of stroke risk, lifetime CVD risk and gender- and ethnicity-specific risk, a press release said. The New Pooled Cohort Equations were derived from a broad group of National Heart, Lung, and Blood Institute-sponsored community-based cohort studies (including Framingham) to better estimate cardiovascular risk and are appropriate for use in non-Hispanic whites and African-Americans from ages 40 to 79. A risk calculator is available. (The new risk calculator has created some controversy. ) The guideline also identified 4 additional measures as potentially helpful when patients or clinicians are still uncertain after using the equations: family history of premature CVD, coronary artery calcium score, high-sensitivity C-reactive protein levels and ankle-brachial index.

The third guideline focuses on lifestyle management and strongly recommends a heart-healthy dietary pattern as the first step to lower risk of CVD. Specifically, Americans should limit saturated fat, trans fat and sodium and emphasize fruits, vegetables and whole grains, while including low-fat dairy products, poultry, fish and nuts and limiting red meat, sweets and sugar-sweetened beverages. Physical activity should average 40 minutes of moderate- to vigorous-intensity aerobic exercise 3 to 4 times a week. Further details are available in a press release.

A final guideline, developed in collaboration with The Obesity Society, offered advice on tailoring treatment recommendations for overweight and obese patients. Clinicians should calculate patients' body mass index (BMI) annually or more frequently and, for patients who need to lose weight, should develop individualized weight loss plans that include a moderately reduced-calorie diet, increased physical activity and behavioral strategies. Adults with a BMI of 40 or higher, or 35 or higher with 2 other cardiovascular risk factors, should be advised that bariatric surgery may provide significant health benefits, a press release noted.

The expert panels that wrote the reports were convened by the National Heart, Lung, and Blood Institute of the National Institutes of Health. The full reports were published on the websites of the ACC and the AHA and will appear in future print issues of the Journal of the American College of Cardiology and Circulation. The obesity guideline will also appear in Obesity: Journal of The Obesity Society.