The 2013 American College of Cardiology/American Heart Association (ACC/AHA) Cholesterol Guidelines, based solely on a limited number of randomized controlled clinical trials with statin therapies, recommended reductions of LDL-cholesterol (LDL-C) by >50% or 30-50% for various populations based on trial data and clinical outcomes. The authors of the document stated they were “not for or against targets” ….but not including guidelines with cholesterol targets or goals led to confusion and controversy amongst experts, clinicians, and patients.
The need for experts to recommend treatment options beyond statin therapy, for practitioners who’s patients had residual risks, recurrent events, Familial Hypercholesterolemia, etc. was not addressed in the 2013 ACC/AHA cholesterol recommendations. Then, in 2015, when the new, very potent LDL-cholesterol lowering PCSK9 inhibitors were approved by the FDA for additional LDL-lowering on top of statin therapy, the need for expert recommendations beyond statin therapy intensified.
The most recent lipid focused expert guidelines in the US were released in March at the American College of Cardiology 2016 Scientific Sessions in Chicago, IL. The document, now published in the Journal of the American College of Cardiology, is titled the “2016 ACC Expert Consensus Decision Pathway on the Role of Non-Statin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk: A Report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents.” These new recommendations, endorsed by the National Lipid Association (NLA), again include lipid numbers to help direct patient care related to cardiovascular risk reduction and our therapy options. For example, for secondary prevention, authors of the new recommendations state one may “consider LDL-C <70 mg/dL or non-HDL-C<100 mg/dL with diabetes” and for patients on high intensity statins who do not get >50% lowering of LDL-C, the authors state that clinicians “may consider adding a non-statin if LDL-C is >100 mg/dL or non-HDL-C is > 130mg/dL.
So, although the semantics are a bit different, “thresholds” vs. targets or goals…..yes, they’re back!