Dyslipidemia Podcast

Top 10 Take-home Messages From the 2018 ACC/AHA Cholesterol Guidelines

Laurence Sperling, MD; Neil J. Stone, MD

Disclosures

December 15, 2021

This transcript has been edited for clarity.

Laurence Sperling, MD: Welcome to Medscape's InDiscussion series on dyslipidemia. This is episode four, "The Top 10 Take-Home Messages From the 2018 ACC/AHA Cholesterol Guidelines." Today we are fortunate to have one of the co-chairs of the 2018 cholesterol guidelines joining us as a guest, Dr Neil Stone. I'll introduce him shortly.

Of course, this is a critically important topic we'll focus on today. Our guidelines are always in evolution, and importantly, our guidelines should guide us. They're not necessarily something we need to follow per dictum, but we do want to partner with our patients to implement the guidelines at the highest level, because these are focused on proven and effective approaches to cardiovascular risk reduction.

We'll start out with a case. This is a pretty typical case. This is a case of Mrs P. She's a 65-year-old woman of South Asian ancestry who's seen in the office of her primary care physician to establish care. She's asymptomatic. She shares that heart disease runs in her family. Her father had a heart attack at age 48. She's a nonsmoker and is nondiabetic. She follows a vegetarian diet. She has a past medical history notable for gestational diabetes and systemic lupus erythematosus.

Her exam and labs are consistent with metabolic syndrome. Her in-office blood pressure is 132/88 mmHg. Her high-density lipoprotein (HDL) cholesterol level is 34 mg/dL. Her fasting triglyceride level is 160 mg/dL and low-density lipoprotein (LDL) cholesterol level is 132 mg/dL, with a total cholesterol of 198 mg/dL. Her primary care physician had read the guidelines and uses the ACC/AHA risk estimator to calculate a 10-year atherosclerotic cardiovascular disease (ASCVD) risk of 7.5%. She asks for guidance regarding heart disease prevention. She presently takes no medications. What would our listeners do with a case like this? We'll certainly come back to this case.

As I mentioned, we have one of the co-chairs of the 2018 cholesterol guidelines joining us today as a guest: Dr Neil Stone, who's the Robert Bonow Professor of Cardiology and Preventive Medicine at the Northwestern Feinberg School of Medicine. He is also the Suzanne and Milton Davidson Distinguished Physician and Medical Director of the Vascular Center at the Northwestern Memorial Hospital. Welcome this morning, Dr Stone.

Neil J. Stone, MD: Thanks, Larry, for having me on the show. I really appreciate it.

Sperling: Neil, everybody knows you very well as a guru, as an expert. You've been carrying the torch of the cholesterol guidelines for many years, and even experts around the country call on you for guidance and expertise. But before we dive into the guidelines and the top take-home messages, tell us a fun fact about you that many of our listeners may not be aware of.

Stone: I do magic tricks. I've done them since my teenage years and now mainly for grandchildren's birthdays. But I even did that as an intern in Boston at the Brigham when I had a very depressed young woman with a difficult diagnosis, and to cheer her up, I did a special magic trick where I predicted the card she drew from an imaginary deck. She started to laugh, and she began to trust her medical team. And it made a major difference. So periodically I pull out a magic trick or two to help the mood in certain patients.

Sperling: Today we're going to talk about the magic of the 2018 cholesterol guidelines. As co-chair of these guidelines and the guideline writing committee, can you share with our listeners why, with these particular guidelines, there was a very definite intention to lead with these top take-home messages, the top 10 take-home messages?

Stone: There are several reasons. Many clinicians said that they don't have time to read guidelines that are 20 or 30 pages — they're too long. Some commentators also didn't quote the guidelines accurately or took them out of context, so clinicians got mixed messages. My idea was to come up with a list of top 10 take-home messages right at the start of the guideline, so the clinicians knew exactly what we said and knew what the emphasis was. Indeed, that became so popular that other ACC/AHA guidelines now start with these top 10 messages. And I encourage every clinician to read these when new guidelines come out.

Sperling: That's great advice. So for our listeners, if you don't have time to read the entire cholesterol guidelines, just go straight to the top 10 take-home messages. We'll start with top take-home message number one, Neil: To reduce risk for ASCVD in all individuals, we should emphasize a heart-healthy lifestyle across the life course. Can you discuss why this was top take-home message number one?

Stone: Absolutely. We wanted to be sure that clinicians understood emphatically how important lifestyle was. Lifestyle considerations should be addressed over the entire life course, and we wanted to put it number one as a way of our adding emphasis to any messages in the guidelines. There are numerous messages about lifestyle. So we want messages to start early.

Realize that lifestyle is always present. Even when drug therapy is given, you need both. I always say to patients, which arm do you want me to cut off, my medication arm or my lifestyle arm? You've got to have both of these. Indeed, our recent ACC consensus statement on triglycerides that I was part of emphasized lifestyle as the initial treatment for elevated triglycerides, and that's right out of the 2018 guidelines.

Sperling: That's a really important comment. We should always remember that combination therapy is the combination of lifestyle and behavioral approaches as the foundation and then thinking about medical therapy. We talked about this particular case, Mrs P, a 65-year-old woman. And we know that in cardiovascular disease prevention, risk assessment is the foundation.

Can you provide some words of wisdom for our listeners regarding how they can build this into their clinical workflow? And then we'll come back to the case of Mrs P, and I'll ask you to comment about her cardiovascular risk and risk-enhancing factors. So first, just how do busy clinicians focus on making sure that each and every one of their patients has a cardiovascular risk assessment?

Stone: I think it all comes down to a simple question to the patient: Do you want to reduce your risk for heart attack and stroke? Almost always, the answer is "yes." And so we say, all right, we agree with you, and we try to point out that the benefit from risk reduction strategies is proportional to the risk. Measuring major risk factors can determine how much short-term risk (that's 10 years) or lifetime risk a patient has.

We pointed out that the lifetime risk estimator is especially useful for those who are 20-39 years of age, because there's no 10-year risk estimation for those patients. Here lifetime risk, which is just an estimation, can be central to any discussion about why lifestyle changes need to start sooner rather than later, so they can see that lifetime risk. The 10-year risk assessments are also sensitive to age. It really starts to pile up as you get older, and it's much lower when you're younger. And they're also sensitive to other factors. So you've got to put into context who the individual is. They can be a real guide to what's going on, but it's where you begin the risk discussion, it's not where you end it.

Sperling: Thanks, Neil. In the 2018 guidelines, there was an emphasis on risk-enhancing factors. Maybe describe those for our listeners, and then we'll come back to Mrs P, because heart disease runs in her family. She's of South Asian ancestry. She has a history of gestational diabetes and lupus as well as the metabolic syndrome. So I just counted on my left hand five risk-enhancing factors for this patient. What's a risk-enhancing factor? Why should our clinicians pay attention to these in their patients beyond that risk assessment?

Stone: We highlighted risk-enhancing factors as long-term descriptors of risk. Notice the word "long-term." Individual enhancing factors may not move the needle much in terms of changing the 10-year risk. That was a popular misconception. We pointed out that knowing all of these special factors allows you to personalize the risk.

Let's take a look at Mrs P. As you pointed out, South Asian ancestry, family history of premature heart disease, lupus, gestational diabetes, and her age — being a person her age tells us that her risk is above and beyond what that 10-year calculation is. Suddenly she sees that heart attack is possible in her lifetime. It changes the conversation so she can better understand why we're interested in addressing her risk.

Sperling: One of the points that was made in the guideline evolution was the concept of LDL thresholds, as we should think about additional therapy — maybe nonstatin therapy — above and beyond appropriate statin intensity. But in the past, I know there have been some questions and even some controversy about thresholds vs targets. So why thresholds? And how do you use the concept of a target? And why are there no definitive target-based goals?

Stone: A lot of people are confused about thresholds, targets, and goals. Obviously, the general goal is to get the LDL low and proportional to the actual risk of the patient. The guidelines are more specific, but we got more specific by talking about thresholds over targets.

Let me give you an example. Before 2013, many patients in primary prevention were treated to an arbitrary target of 100 mg/dL. And I saw two types of people. I saw high-risk people whose LDLs were 90 or 95 mg/dL, so they were under 100 but actually were very high risk — diabetes, smoking, hypertension, they weren't on a statin. And then there were very often these middle-aged or slightly older women who had LDLs of 130 or 140 and no other risk factors. They had a perfect risk profile. No enhancing factors, no nothing. And they were getting a statin because their doctors were treating the LDL when clearly that person with the LDL of 95 had a much higher risk — 10-year and lifetime risk — than the person with the LDL of 130 or 140 who otherwise looked really good.

So we like the idea of a threshold where the clinician has to stop and say, this person is over the threshold. Do they have the kind of risk that makes sense for me to treat? And if they're under the threshold, if they get under that number, that doesn't mean it's over, because there's nothing magical about 100 mg/dL. Cholesterol and LDL cholesterol risk is continuous, as everybody knows; 99 and 101 are not different numbers, probably. And so it allows you to stop and think.

We saw that in secondary prevention, where we say in our 10 take-home points in very high-risk secondary prevention, use an LDL threshold of 70 after you've already lowered the LDL by 50% with a high-intensity statin. And that allows you to consider nonstatins. What we're saying is if we set a target of 70, the person might have an LDL of 65 or 68 and have multiple factors that indicate why they should be on very aggressive therapy. A threshold gives the clinician more leeway.

Sperling: So we heard from this part-time magician that an LDL of 100 mg/dL is not magical. But you want to focus on the whole of the patient and really pair their risk to the intensity of therapy, which brings us to a point that has been made now through the last two iterations of the cholesterol guidelines, and that's statin intensity. For the majority of our patients, unless there's significant hypertriglyceridemia, a statin should be the first-line therapy. I think in 1987, the first statin came on the market. So we have long-term data with statins, very consistent in terms of risk reduction. But for our listeners today, why has there been this emphasis on statin intensity? What does that mean, and what should we be striving for in our high-risk patients?

Stone: That's a great question, Larry. A lot of patients say, Dr Stone, I'm okay with taking a statin. I want the teeniest dose possible. And I go, I thought you said you wanted to reduce your risk for heart attack and stroke. I always clarify that at the start. And they go, I do. I say, well, the benefit from the statin is directly proportional to how much the LDL is lowered. A moderate-intensity statin lowers LDL about 30% or 40%, but high-intensity lowers it 50% roughly, or more.

If you want to get reductions in heart attack and stroke — and in secondary prevention for total mortality and in high-risk primary prevention for total mortality — then you've got to be on an adequate statin. Because for every 40 mg of LDL that gets lowered, it's roughly 1 mmol. A millimole is 38.7 mg, but we round it to 40 so everybody understands it. For every 40 mg of LDL, you get a 22% risk reduction.

So take a patient with an LDL of 160 mg/dL. When he or she gets the LDL lowered to 80 by a high-intensity statin, they get 44% reduction in risk. Whereas if you give them just a teeny amount of statin and they lower their LDL by 20%, they get much, much less lowering. So it's very powerful. But I point out that intensity matters most when your risk is highest. That's the point.

Sperling: And several times, I've heard you make the point that when we communicate with our patients, we want to point out that our goal is cardiovascular risk reduction, not LDL cholesterol reduction. I read a recent paper from the GOULD Registry that really for me hit home. It was a questionnaire of patients and also of clinicians, and the majority of patients don't really understand why they're prescribed a statin. They think it's a medicine to lower their cholesterol, and frequently they will stop it after several months because their cholesterol is lower and they don't understand the need for longitudinal therapy.

The other thing they don't understand is the biological effects of a statin and the effects on lowering the risk for heart attack, stroke, and cardiovascular event rates. You've taught me a lot over the years about how to have the right conversation with our patients. Just mention for a moment about the clinician-patient risk discussion and then, how do we help our patients understand the importance of adherence and the response to LDL-lowering medications? Maybe share some pearls, because I know you've shared many pearls with me over the years that I certainly keep in my back pocket.

Stone: Thanks, Larry. We started the emphasis on the clinician-patient risk discussion in the 2013 guidelines. Again, we put that front and center, this risk discussion, in the top 10 take-home messages because many times commentators or patients missed the idea of how important it was to have the clinician-patient discussion before you start statin therapy. We always said your 10-year risk doesn't prescribe the statin. The risk discussion does. You've got to put that 10-year risk in context and you've got to discuss the potential for benefit, the potential for negative effects. And we have these discussions now with people wondering about immunizations — is the potential for benefit much, much higher than any potential for risk?

Putting that into context allows people not to walk so timidly into drug therapy of any kind. It's particularly true of statins, where many times patients have been told that these are very difficult drugs, and I can point out that most patients tolerate them just fine. I've been on them for over 30 years because we have very high heart disease risk in my family. And the point is that I think it matters, the mindset.

Studies recently have shown that people who complain of aches and pains on a statin also get the same aching on a placebo. There's a lot of this nocebo effect there. That doesn't mean that some people don't have real side effects, but the number is smaller, not larger. Most people can take statins, and doctors can reassure patients that in this case, if you follow the guidelines, the benefits should exceed the risks.

Sperling: Well, thanks. What I'd like to do now is come back to the case of Mrs P. I asked our listeners to think about how they would approach such a case. What I'll say here is that the primary care physician taking care of Mrs P had read the top take-home messages of the 2018 cholesterol guidelines and was very familiar with the clinician-patient risk discussion. This was an ongoing discussion with Mrs P initially about her risk. And after 6 months of lifestyle and behavioral improvements, there were modest improvements in her triglycerides and her HDL.

After a discussion about the risk reduction benefits of statins and the potential side effects of a moderate-intensity statin, an agent was initiated, and she tolerated this quite well. So this was a successful at least start of a cardiovascular preventive effort — primary prevention in a woman who, even though her 10-year ASCVD risk was calculated at 7.5%, because of multiple risk-enhancing factors, it's likely her risk is higher than estimated.

Since we have this opportune moment to have Dr Neil Stone with us, the co-chair of the 2018 cholesterol guidelines, as our guest today for InDiscussion, I'd like to conclude by asking Dr Stone, for our listeners, can you provide a top take-home message?

Stone: The top take-home message for me is, number one, understand the patient's risk for heart attack and stroke and find out how meaningful reducing heart attack and stroke is. Patient P's father died at age 48. Patient P had lots of other personal factors that suggested that she was at risk. So spend a little time talking about risk, not just the numbers, because that makes more sense, I believe, to the patient. But it's by the numbers that we can determine the intensity of our therapy.

And then I want to point out that we also mentioned in our top 10 that if she was uncertain about the benefit of a statin, a coronary artery calcium score has been shown to be very effective in helping the patient see that risk, because a certain number of patients who may be on the borderline may have a 0 score. So the bottom line is, I tell people that I'm trained to treat cholesterol, but I always start with understanding risk.

Sperling: Thank you very much. Today we've been speaking about the top take-home messages of the 2018 cholesterol guidelines with Dr Neil Stone. Today, Neil, you've shared a lot with us. I hope our listeners will take some of your pearls and words of wisdom back to the office when they start caring for patients, either tomorrow or next week.

And for our listeners, our next episode will be nonpharmacologic approaches to cholesterol management with Dr Kim Williams, who's the director of cardiology at the Rush Medical Center and a past president of the American College of Cardiology. For Medscape InDiscussion, this is Dr Laurence Sperling.

Resources

2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol

ASCVD Risk Estimator Plus

2021 ACC Expert Consensus Decision Pathway on the Management of ASCVD Risk Reduction in Patients With Persistent Hypertriglyceridemia

What Do US Physicians and Patients Think About Lipid‐Lowering Therapy and Goals of Treatment? Results From the GOULD Registry

Statin Treatment and Muscle Symptoms: Series of Randomised, Placebo Controlled n-of-1 Trials

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