November 10, 2018
Leading
heart experts released cholesterol management guidelines Saturday that call on
doctors to tailor treatment to more personalized risk assessments of each
patient and recommend the use of two new kinds of drugs for those at the
greatest danger of disease.
The recommendations build on and address criticism of guidelines issued in 2013 that
fundamentally altered the way health-care providers determine a patient’s risk
of heart attack and cardiovascular disease. In that watershed document, the
experts told doctors to stop trying to lower patients’ cholesterol numbers to
specific targets and instead follow an overall matrix that attempts to predict
their future risk of problems.
The
latest guidelines give clinicians a better idea of how to do that via treatment
categories that vary depending on cholesterol scores and, if necessary, other
tests. The 121-page document was unveiled Saturday at the American Heart
Association’s 2018 Scientific Sessions in Chicago and published in the Journal
of the American College of Cardiology and the heart association’s journal,
Circulation.
“We
essentially are endorsing and expanding the scope of the risk discussion,” said
Neil J. Stone, vice chairman of the committee that wrote the guidelines and a
cardiology professor at Northwestern University’s Feinberg School of Medicine.
For
example, the guidelines recommend “high-intensity” statin therapy for people
under the age of 75 who are determined to have atherosclerotic cardiovascular
disease, with the goal of reducing their low-density lipoproteins (LDL), or
“bad,” cholesterol by 50 percent. In people aged 40 to 75 with diabetes,
“moderate-intensity” statin therapy is indicated regardless of the patient’s
10-year risk of disease, according to another recommendation.
Heart
disease is the leading killer of Americans. Nearly a third of all U.S. adults
have high LDL levels, a major cause of fatty deposits in arteries that lead to
heart attacks, strokes and other cardiovascular problems.
The
recommendations reaffirm the guiding principles of heart health that “lower is
better” when it comes to LDLs, and that people should try to achieve that first
by living a healthy lifestyle, starting in childhood. That includes diet and
exercise, controlling blood pressure and avoiding smoking, among other
measures.
When
those steps aren’t sufficient, the guidelines again endorse statins as the
cornerstone of preventive treatment for people at risk of disease. About 43
million people in the United States take statins to lower their LDL levels. The
drugs are credited with reducing the risk of heart attacks and strokes.
Parag
Joshi, an assistant professor of medicine at the University of Texas
Southwestern Medical Center in Dallas, who conducts research in preventive
cardiology, said the guidelines combine the old emphasis on LDL scores with the
approach outlined in 2013. The move away from LDL scores was loudly criticized
by some clinicians when the 2013 recommendations were issued.
Joshi said that in the intervening five years research has shown
“really high quality evidence that we can go for [LDL scores of] lower than 70
and do it with these [newer] medicines.”
Two drugs have been developed since the last guidelines were
issued in 2013, and the panel endorsed their use in cases when statins are not
sufficient. For people who have suffered a heart attack or have numerous
high-risk conditions, experts suggest adding ezetemibe. The drug, which is
marketed as Zetia but is also available in generic form, decreases the amount
of cholesterol absorbed in the small intestine.
In some cases, experts also recommend the use of PCSK9 inhibitors, powerful drugs approved by
the Food and Drug Administration in 2015 that block a substance that hinders
the liver’s ability to remove LDLs from the blood. The drugs, used mainly to
treat an inherited disorder that causes very early heart attacks, are
enormously expensive, and the panel offered physicians a way to assess their
value.
The committee estimated PCSK9 inhibitors cost more than $150,000
for every good year of life added. Amgen, the drug company that makes the PCSK9
inhibitor Repatha, cut its list price in October to $5,850 per year to make it
more affordable, a spokeswoman said.
When doctors have a difficult time deciding how to treat
patients, the committee suggests coronary artery calcium tests can be helpful
in determining how much plaque has built up on the walls of certain blood
vessels. They raised the prospect of beginning cholesterol testing much earlier
in life, to identify children at risk of developing heart disease.
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