New choles­terol guide­lines push per­son­al­ized care

The News Tribune - - Nation & World - BY LENNY BERN­STEIN Wash­ing­ton Post

Lead­ing heart ex­perts re­leased new choles­terol man­age­ment guide­lines Satur­day that call on doc­tors to tailor treat­ment to more per­son­al­ized risk as­sess­ments of each pa­tient and rec­om­mend the use of two new kinds of drugs for those at the great­est dan­ger of dis­ease.

The rec­om­men­da­tions build on guide­lines is­sued in 2013 that fun­da­men­tally al­tered the way health care providers de­ter­mine a pa­tient’s risk of heart at­tack and car­dio­vas­cu­lar dis­ease. In that wa­ter­shed doc­u­ment, the ex­perts told doc­tors to stop try­ing to lower pa­tients’ choles­terol num­bers to spe­cific tar­gets and in­stead fol­low an over­all ma­trix that tries to pre­dict their fu­ture risk of prob­lems.

The new guide­lines give clin­i­cians a bet­ter idea of how to do that via treat­ment cat­e­gories that vary de­pend­ing on choles­terol scores and, if nec­es­sary, other tests. The 121-page doc­u­ment was un­veiled Satur­day at the Amer­i­can Heart As­so­ci­a­tion’s 2018 Sci­en­tific Ses­sions in Chicago and pub­lished in the Jour­nal of the Amer­i­can Col­lege of Car­di­ol­ogy and the heart as­so­ci­a­tion’s jour­nal, Cir­cu­la­tion.

“We es­sen­tially are en­dors­ing and ex­pand­ing the scope of the risk dis­cus­sion,” said Neil Stone, vice-chair­man of the com­mit­tee that wrote the guide­lines and a car­di­ol­ogy pro­fes­sor at North­west­ern Uni­ver­sity’s Fein­berg School of Medicine.

For ex­am­ple, the guide- lines rec­om­mend “high­in­ten­sity” ther­apy with statins for peo­ple un­der the age of 75 who are de­ter­mined to have atheroscle­rotic car­dio­vas­cu­lar dis­ease, with the goal of re­duc­ing their LDL, or “bad,” choles­terol by 50 per­cent. In peo­ple aged 40 to 75 with di­a­betes, “mod­er­ate-in­ten­sity” statin ther­apy is in­di­cated re­gard­less of the pa­tient’s 10-year risk of dis­ease, ac­cord­ing to an­other rec­om­men­da­tion.

Heart dis­ease is the lead­ing killer of Amer­i­cans. Nearly a third of all U.S. adults have high LDL lev­els, a ma­jor cause of fatty de­posits in ar­ter­ies that lead to heart at­tacks, strokes and other car­dio­vas­cu­lar prob­lems.

The new rec­om­men­da­tions reaf­firm the guid­ing prin­ci­ples of heart health that “lower is bet­ter” when it comes to LDLs, and that peo­ple should try to achieve that first by liv­ing a healthy life­style, start­ing in child­hood. That in­cludes diet and ex­er­cise, con­trol­ling blood pres­sure and avoid­ing smok­ing, among other mea­sures.

When those steps aren’t suf­fi­cient, the guide­lines again en­dorse statins as the corner­stone of pre­ven­tive treat­ment for peo­ple at risk of dis­ease. About 43 mil­lion peo­ple in the U.S. take statins to lower their LDL lev­els. The drugs are cred­ited with re­duc­ing the risk of heart at­tacks and strokes.

Two new drugs have been de­vel­oped since the last guide­lines were is­sued in 2013, and the panel en­dorsed their use in cases when statins are not suf­fi­cient. For peo­ple who have suf­fered a heart at­tack or have nu­mer­ous high-risk con­di­tions, the ex­perts sug­gested adding ezetemibe. The drug, which is mar­keted as Ze­tia but is also avail­able in generic form, de­creases the amount of choles­terol ab­sorbed in the small in­tes­tine.

In some cases, the ex­perts also rec­om­mended the use of new PCSK9 in­hibitors, pow­er­ful drugs ap­proved by the Food and Drug Ad­min­is­tra­tion in 2015 that block a sub­stance that hin­ders the liver’s abil­ity to re­move LDLs from the blood. The drugs, cur­rently used mainly to treat an in­her­ited disor­der that causes very early heart at­tacks, are enor­mously ex­pen­sive, and the panel of­fered physi­cians a way to as­sess their value.

The com­mit­tee said PCSK9 in­hibitors cost more than $150,000 for ev­ery good year of life added.

HEART DIS­EASE IS THE LEAD­ING KILLER OF AMER­I­CANS. NEARLY A THIRD OF ALL U.S. ADULTS HAVE HIGH LDL LEV­ELS, A MA­JOR CAUSE OF FATTY DE­POSITS IN AR­TER­IES THAT LEAD TO HEART AT­TACKS, STROKES AND OTHER CAR­DIO­VAS­CU­LAR PROB­LEMS.

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