New Guidelines for Cholesterol Management
Heart disease remains the number one cause of death in the United States, making it a major public health concern. In an attempt to reduce the risk of heart disease, the American College of Cardiology and the American Heart Association task force recently released updated guidelines for how physicians should treat elevated cholesterol.1
The newly released 2018 guidelines are an update to the 2013 guidelines which were developed to help reduce heart attack and stroke risk by lowering blood cholesterol. Although the guidelines do recommend a heart-healthy lifestyle as one part of the puzzle, the majority of the document focuses on prescribing medications as a primary way to reduce risk of cardiovascular disease.
The report emphasizes a heart-healthy lifestyle for people of all ages. It recommends that a focus on heart health should start early, as a first line of intervention in young adults in their 20s, to help assess and reduce lifetime risk factors.
Recommendations for decreasing risk of heart disease include following a diet that is moderate in calories and also high in vegetables, fruits, whole grains, legumes, and low-fat protein sources. Foods that should be limited include sweets, sugar-sweetened beverages, and red meat. The report also recommends 3 to 4 sessions a week of moderate to vigorous physical activity, lasting 40 minutes or more.
There is an emphasis in the report that in order to lower heart disease risk, doctors must also address metabolic syndrome. Metabolic syndrome, which affects 1 in 3 US adults, is defined by a cluster of symptoms including: abdominal obesity, high triglycerides, low HDL, elevated blood pressure, and high blood sugar. The report recommends that before the initiation of statin therapy, lifestyle factors should be addressed to help lower risk.
A Focus on Statins
The remainder of the 2018 report focuses on when to use statins to help manage cholesterol and reduce the risk of heart disease. It states that serum cholesterol and the lipoproteins, such as LDL, VLDL, and HDL, are known risk factors for heart disease. In order to reduce risk, doctors should aggressively reduce VLDL, the primary carrier of triglycerides, as well as LDL commonly referred to as “bad” cholesterol. These two lipoproteins in combination have been found to significantly increase the risk of cardiovascular disease.
The goal for the general population without any specific risk factors is to maintain a total cholesterol of 150 mg/dL and an LDL of 100 mg/dL, with a consensus that lower is better for LDL. The report suggests an LDL goal of 70 mg/dL for those at very high risk for cardiovascular disease. Statin medication may not be enough to lower LDL to this level, therefore it may require the use of other cholesterol lowering medications in combination. Those with diabetes and an LDL greater than 70 mg/dL should also receive high-intensity statin therapy.
There are a few situations discussed in the report where the initiation of statin therapy is left up to the clinical opinion of the primary physician. These situations include those with risk factors such as smoking, blood glucose, and high blood pressure, but who do not currently have elevated cholesterol.
Finally, the report suggests monitoring those receiving statin therapy every 3 to 12 months and to adjust dosage as needed.
Managing Side Effects
There is some discussion about managing the side effects of statin use. The overarching recommendation is to continue the statin treatment even in light of side effects, due to the potential greater risk of heart disease.
One common side effect of statin use is muscle pain. A recent meta-analysis published in the Journal of the American Heart Association found that supplementation with CoQ10 can help manage these symptoms.2 However, this report by the ACC and AHA does not recommend using CoQ10. Instead, they utilized a single study published in 2015 that found no improvement in muscle pain with using CoQ10.3
Another report is expected every five years as research continues to develop regarding statin use, heart disease risk, and managing side effects of treatment.
- Blog Contributor