Statins to manage CV risk according to new ACC/AHA guidelines on CV prevention

The American College of Cardiology (ACC) and the American Heart Association (AHA) have published four new guidelines that focus on the prevention of cardiovascular (CV) disease. The guidelines discuss better risk assessment and management of cholesterol, lifestyle and weight.

Both the ACC and the AHA aim to prevent CV disease and improve care of people living with or at risk of CV disease. The guidelines should help at achieving this, by providing guidance to various health care professionals (including primary care physicians, pharmacists, nurses and specialists) in how to best manage care, based on evidence up through 2011.
 One of the guidelines introduces a new way to estimate a patient’s risk of having an atherosclerotic CV disease event in the next 10 years, incorporating the patient’s age, sex, total and HDL cholesterol, systolic blood pressure, blood pressure treatment, diabetes and smoking. In contrast to previous risk assessment tools, the new equation considers risk of stroke. It should help predict which patients will benefit most from interventions. Additional factors are discussed that may help to further define a patient’s risk.

Modifying cholesterol levels

The guideline that deals with management of blood cholesterol levels no longer gives hard treatment targets for LDL and non-HDL cholesterol. Rather, it is recommended that an appropriate intensity of therapy is determined for a given patient, in order to reduce his or her risk in combination with a heart-healthy lifestyle. The guideline advises to give statin therapy irrespective of LDL cholesterol levels, thus frequent blood testing is no longer recommended.
Among all lipid-lowering therapies, statins show the strongest evidence for a favourable risk-benefit ratio. Four groups of patients are described that are considered to benefit the most from statin therapy: those with a history of CV disease, those with LDL-c>190 mg/dL, patients with diabetes aged 40-75 without a history of clinical atherosclerotic CV disease and LDL-c of 70-189 mg/dL, those with a 10-year CV risk according to the new equation but without a history of CV disease.
Based on the new guideline, the number of patients receiving statin therapy is expected to increase. The guideline recommends that the first two groups receive high-intensity statin therapy, and when moderate-intensity treatment may suffice, based on the new risk assessment equation.

Lifestyle management

The guideline on lifestyle management focuses on the importance of a healthy dietary pattern, which included many fruits, vegetables, whole grains, low-fat dairy, legumes, fish, poultry, and nuts, while sweets, sugar-sweetened beverages and red meats should be consumed with moderation. Evidence is provided that restricted intake of saturated fat and trans-fat can reduce cholesterol levels, and that sodium restriction can help reduce blood pressure.
40 minutes of moderate-to-vigourous physical activity on 3 to 4 days a week is recommended.

Management of overweight and obesity

The last new ACC/AHA guideline considers maintenance of a healthy weight, and was developed in collaboration with the Obesity Society. It is recommended to use body mass index as a quick first evaluation, to be complemented by a measurement of waist circumference, in order to determine risk of CV disease, diabetes and death.
Evidence is given that even modest weight loss of about 3-5% is associated with clinically meaningful benefits. No specific diet is recommended to achieve weight loss. Rather, recommendations to reduce caloric intake should be based on patient preferences and health status.
The guideline strongly advises at least 6 months of counselling on diet and exercise, or even comprehensive specialised programmes to loose weight.
Bariatric surgery is considered an appropriate option in patients with a BMI of >35 kg/m² and obesity-related comorbidities, or with BMI >40 kg/m² regardless of comorbidities.

Sources

2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Goff DC, Lloyd-Jones DM, Bennett G, et al., J Am Coll Cardiol. Published online November 12, 2013. doi:10.1016/j.jacc.2013.11.005
2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Stone NJ, Robinson J, Lichtenstein AH, et al., J Am Coll Cardiol. Published online November 12, 2013. doi:10.1016/j.jacc.2013.11.002
2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Eckel RH, Jakicic JM, Ard JD et al., J Am Coll Cardiol. Published online November 12, 2013. doi:10.1016/j.jacc.2013.11.003
2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society Jensen MD, Ryan DH, Apovian CM, et al., J Am Coll Cardiol. Published online November 12, 2013. doi:10.1016/j.jacc.2013.11.004