Confusion About Guidelines Contributes to Suboptimal LDL Management

Given its etiologic role in atherogenesis, the management of risk related to low-density lipoprotein (LDL) has become a vital part of treating patients in danger of atherosclerotic cardiovascular disease (ASCVD). While multiple approaches have been developed to lower LDL cholesterol and reduce ASCVD-related risk, significant lapses in care continue to exist.

To address this issue, the American College of Cardiology (ACC) launched a three-year, multistakeholder quality initiative: LDL: Address the Risk, which aims to improve patient outcomes and increase awareness of gaps in lipid management and the importance of managing LDL-related risk. To kick off the initiative, the ACC convened a think tank to establish the key issues surrounding LDL-related dyslipidemia to inform efforts moving forward.

The think tank took place last year and included representatives of 17 medical specialty societies and other experts in cardiovascular disease risk and reduction and lipidology. During the think tank, substantially different guideline recommendations for the management of LDL in patients at risk for ASCVD were discussed as a reason for the suboptimal management of at-risk patients.

A review based on proceedings from the think tank summarized the current guidelines for reducing LDL-related cardiovascular risk developed by the National Cholesterol Education Program Adult Treatment Panel, the International Atherosclerosis Society, the European Society of Cardiology/European Atherosclerosis Society, the Canadian Cardiovascular Society and the American Association of Clinical Endocrinologists (J Am Coll Cardiol 2014;64[2]:196-206). It also touched on the 2013 ACC/American Heart Association Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults, which addresses only a limited number of critical questions and does not provide comprehensive recommendations for the management of all forms of dyslipidemia.

In the face of such disparate guidelines, many clinicians and patients still have questions regarding the new recommendations. Not only are clinicians seeking simple tools to help with guideline implementation, they also need more information on the management of patients not considered in one of the four statin benefit groups (i.e., those with high lifetime ASCVD risk and those with complex dyslipidemias).

Patients are questioning the implications of initiation of therapy with high-dose statins, the lack of specific numeric goals of the therapy and the reduced monitoring of statin therapy by laboratory assessment. Patients require a careful explanation of the risks of dyslipidemia and a better understanding of the benefits of lifestyle therapy as well as the risks and benefits of pharmacologic strategies for management of LDL-related risk.

Moving forward, the ACC's LDL: Address the Risk initiative is using the outcomes from the think tank to develop more effective strategies and tools for clinicians and patients to assist in ensuring guideline-recommended therapy is implemented. In addition, professional societies should work together in the near future to develop guidelines based on unified principles of treatment for reduction of ASCVD risk, high-quality evidence from large randomized clinical trials and other types of research. Further, a focus on individualized care and special patient populations not included in current guidelines is urged.

Education of providers on the process of guideline development and strategies for integration of existing guidelines will be important to successfully manage high-risk patients. Clinicians and patients will benefit from the understanding that these recommendations serve only as a starting point for care of the individual patient. Clinical judgment and patient preference must play important roles in the therapeutic decision.

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