This viewpoint was originally posted on the website of the International Atherosclerosis Society.

Common Efforts: New Lipid Guidelines Emphasize the Need for Aggressive Treatment in High-Risk People

By Philip Barter

The recent release of the ACC-AHA Lipid Guidelines (ACC/AHA Lipid Guidelines. Circulation; online November 12, 2013) has stimulated much discussion, and has prompted strong responses from both supporters and opponents. There has also been much discussion of how these ACC-AHA guidelines differ from the European Guidelines (ESC-EAS Lipid Guidelines. Eur Heart J. 2011; 32:1769) and the IAS recommendations (IAS Lipid Management Recommendations. J Clin Lipidol. 2014; 8:29).
Despite the unfortunate focus on differences in many of these discussions, it is important to note that the recommendations from all three groups agree on almost all important points, with the small differences representing fine-tuning rather than major disagreements.

Points of Agreement

There are 10 fundamentally important points on which all three documents agree.

1. A decision to use lipid-lowering drugs should be based on an assessment of overall long-term cardiovascular (CV) risk rather than simply on a perceived need to treat an abnormal lipid level.

2. High risk people include those with:
• Manifest atherosclerotic cardiovascular disease (ASCVD)
• Familial hypercholesterolemia (FH)
• Diabetes

3. In people without ASCVD, FH, or diabetes, long-term global risk should be calculated and used to guide treatment decisions.
(Note that the method for calculating risk will vary widely from country to country.)

4. Calculation of global risk should take account of both lipid and non-lipid risk factors.

5. There should be a major emphasis on lifestyle intervention whether or not drug therapy is used.

6. LDL-C should be a primary therapeutic target. LDL-C lowering with statins has been proven to reduce ASCVD risk in high-risk people.

7. Statins are indicated in proven high risk conditions:
• Those with manifest ASCVD
• Those with diabetes
• Those with FH
• Those without ASCVD, FH, or diabetes but who are calculated to be at a high lifetime risk of developing ASCVD

8. When the risk is high, treatment should be intensive.
The ESC/EAS and the IAS recommend LDL-lowering therapy to achieve a target level of LDL-C <1.8 mmol/L (<70 mg/dL), while the ACC/AHA recommend the use of high intensity statin therapy to reduce LDL-C by >50%.

9. When the risk is moderately high, treatment should be moderately intensive.
The ESC/EAS and the IAS recommend LDL-lowering therapy to achieve a target level of LDL-C <2.6 mmol/L (<100 mg/dL), while the ACC/AHA guidelines recommend the use of moderate intensity statin therapy to reduce LDL-C by 30 - 50%.

10. There is general agreement that non-HDL-C should be considered as an alternate to LDL-C as a therapeutic target. There are several compelling reasons for considering non-HDL-C as a target.
• Non-HDL-C includes the sum of the cholesterol in all atherogenic lipoproteins rather than only that in the LDL fraction.
• Measurement of non-HDL-C does not require fasting for accurate measurement
• There is growing evidence that the level of non-HDL-C is essentially equivalent to apolipoprotein-B in predictive power and has greater predictive power than LDL-C.

The differences between the ACC-AHA, ESC-EAS, and IAS recommendations are relatively minor.
It will be most unfortunate if these minor differences create a level of confusion that obscures the major points of agreement between all recommendations. We encourage all our readers to focus on the most important aspects of the respective guidelines – those commonalities outlined above – all of which will most benefit our patients.

It is worth noting that the American Guidelines are directed towards America and the European Guidelines are for management in Europe. The new IAS recommendations have been prepared as an aid to countries and regions in the rest of the world. As I have emphasized in the past, the IAS is committed to providing help to countries and regions that wish either to develop (or to modify) their own guidelines.

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