The American College of Cardiology and the American Heart Association, in collaboration with the National Heart, Lung, and Blood Institute and other specialty societies, recently updated its guidelines for treating dyslipidemia in adults (see “Understanding the AHA/ACC's new cholesterol treatment guidelines” on page 42). Many clinicians feel uncertain about the best way to use these new recommendations. For many years, the Adult Treatment Panel (ATP III) guidelines were easily consolidated into a treatment rubric that clinicians comfortably employed.
Several of the new guidelines diverge substantially from previous practice. The thorough review process used to establish these new guidelines included the evaluation of a decade of new clinical trials data, systematic reviews, meta-analyses, and other sources of relevant information. Historically, the ATP guidelines recommended achieving a low-density lipoprotein (LDL) level of less than 100 mg/dL for primary prevention (or less than 70 mg/dL for secondary prevention). The new recommendations abandon the “treat to target” approach for achieving these specific LDL goals. In addition, the “lower is better” philosophy is no longer supported. Instead, customized treatment in both primary and secondary prevention is based on individual risk for atherosclerotic cardiovascular disease. Furthermore, only the use of statins is endorsed for atherosclerotic cardiovascular disease risk reduction, as the benefit of nonstatin agents does not offset their risk.
To assist practicing clinicians in determining patients' degree of risk, an online version of the risk stratification calculator can be found at http://www.cardiosource.org/en/Science-And-Quality/Practice-Guidelines-and-Quality-Standards/2013-Prevention-Guideline-Tools.aspx, and a free mobile device application from the American College of Cardiology is available on the iTunes Store. The bottom line of therapy is to treat to the level of atherosclerotic cardiovascular disease risk. Remember that increasing age substantially increases patient risk.
From a practicing clinician's perspective, targeting the four specific groups at highest risk for cardiovascular disease is crucial. Coupled with these prescriptive recommendations are guidelines specific to body weight management, lifestyle modification, and cardiovascular risk assessment. These recommendations address the key role of diet and physical fitness, including aerobic exercise three to four times a week and a diet high in vegetables, fruits, and whole grains.
Also, updated guidelines for managing hypertension in adults were released in February by the Eighth Joint National Committee (JNC8). These evidence-based guidelines are aimed at simplifying hypertension treatment in the same way that the new lipid guidelines clarify treatment strategies to reduce patients' risk for atherosclerotic disease.
Ultimately, the goal surrounding all of these guidelines is to reduce the morbidity and mortality from atherosclerotic cardiovascular disease, which remains the leading cause of death in developed countries. Physician assistants play a crucial role in the prevention and management of this significant disease process.