Steven Nissen, MD: Takeaways from the Updated Cholesterol Guidelines

Earlier this week, the American Heart Association and the American College of Cardiology released updated guidelines for clinicians on the management of blood cholesterol. The updated guidelines, which were last updated in 2013, were presented at the American Heart Association Scientific Session in Chicago, Illinois.

The guidelines include a focus on reducing atherosclerotic cardiovascular disease (ASCVD) risk, an evaluation of individual risk factors in estimating 10-year CVD risk, and a stepped approach to escalating statin therapy, adding ezetimibe if lipid levels remain high, and finally to introducing a PCSK9 inhibitor if further reduction is required.

Additionally, the guidelines also stressed the importance of a personalized care plan tailored to each patient’s history and risk factors including an update to the risk calculator introduced in the 2013 guidelines that adds risk-enhancing factors as well as conditions including metabolic syndrome, chronic kidney disease, chronic inflammatory conditions, premature menopause or pre-eclampsia, and high lipid biomarkers.

In an exclusive interview, MD Magazine® sat down with Steven Nissen, MD, Chairman of the Department of Cardiovascular Medicine at the Cleveland Clinic to discuss what the key updates in the guidelines are and how they should be interpreted by clinicians.

Interview transcript: (modified slightly for readability)

MD Magazine®: What are the most notable new additions to the updated cholesterol guidelines?

Nissen: These are really very different from the 2013 guidelines. There were many people, including me, that were quite critical of the last set of guidelines. The [2013] guidelines said, just give a statin drug to people who are eligible and don’t worry about targets; treat with the drug, but don’t treat to target.

These guidelines bring back the concept of adjusting therapy for cholesterol levels, and they recommend more aggressive treatment targets for people in very high risk, whose LDL cholesterol is > 70, they recommend treating with a maximal statin dose, but then adding additional drugs such as an ezetimibe or a PCSK9 inhibitor to get to lower levels of LDL cholesterol. That’s really quite a departure from the previous set of guidelines, and I think it’s consistent with what the science tells us, which is that all things being equal, having a lower level of LDL cholesterol is a good thing.

MD Magazine®: Can you speak to the updates of the personalization calculation?

Nissen: I think there’s an increasing recognition that the risk calculator was not an accurate reflection of risk. I was very surprised that the guideline writers, who were some of the people who developed the risk calculator, acknowledged that the risk calculator works for populations, but not for individuals, and so they added some additional elements. They suggest, for example, that if you have a family history of heart disease, that might put you in a different risk category, or an elevated C reactive protein, or diabetes, or other factors.

I’m very pleased that there’s a recognition that the risk calculator, that was originally released in 2013, is flawed and that we need to use other information in order to make better decisions about who to treat. They also emphasize something that many of us have advocated for a long time, that we call shared decision making. You present to the patient the risks and benefits of the therapy and together you arrive at a decision about whether the patient should be treated or not and what level of intensity they should be treated.

There are a couple of other additional changes to the guidelines that are very welcome. The guidelines in 2013 did not address patients over the age of 75 or younger than 40. People who are 75 can live 10, 15, 20 more years and we need to have more information on what to do.

I was very pleased that new guidelines suggest that for appropriate patients with a reasonable life expectancy that treating high cholesterol at ages above 75 is prudent. And that for very high-risk individuals less than 40, it is also reasonable to offer treatment. I think that’s a very sound addition to the guidelines that extends them to a very significant number of people who have risk but are below 40 or greater than 75 years of age.

The guidelines were published simultaneously in the American Heart Association journal, Circulation, and the Journal of the American College of Cardiology. The supplement, “Use of Risk Assessment Tools to Guide Decision-Making in the Primary Prevention of Atherosclerotic Cardiovascular Disease,” was also published in those journals.