Cardiovascular (CV) disease is the major killer of women in developed nations. In late 2013 the American Heart Association (AHA) with the American College of Cardiology (ACC) released new guidelines on the management of dyslipidemia and on lifestyle management of CV risk [1,2]. The new recommendations move away from the previous concept of lowering LDL levels to a specific target based on patient risk. The guideline authors comment that there is no evidence to support the approach of the last decade. Instead they have developed a new risk assessment tool to calculate patient risk and suggest we treat all individuals without established cardiovascular disease over 40yrs of age where there is a 10year cardiovascular risk of greater than 7.5%. The intervention threshold is lowered to 5% if they have diabetes. This approach applies even to patients with normal LDL levels. Other groups identified for therapy include: individuals 1) with clinical CV disease, 2) primary elevations of LDL–C >4.9mmol/L, 3) diabetes aged 40 to 75 years with LDL– C 1.8 – 4.9mmol/L and without clinical CV disease.
The implications of this new approach are significant as it means that roughly 1 in 3 North American adults would require statin therapy.
The new guidelines have been controversial as the new risk calculator  has not been validated and no clinical trial of lipid lowering therapy has recruited patients based on baseline CV risk. Despite a gender difference in the response to statin therapy, the advice of the guidelines is consistent for both men and women.
It is important to be aware of the new recommendations because they will impinge on practice guidelines in Australia and New Zealand. However, there is no replacement for good clinical judgment and assessing our patients' risk in a comprehensive way. Women appear to have less response to statins in the primary prevention setting and have more side effects with therapy so, as clinicians, we need to weigh the risks and absolute benefits of these treatments very carefully.
- Eckel RH, Jakicic JM, Ard JD, Miller NH, Hubbard VS, Nonas CA, de Jesus JM, Sacks FM, Lee IM, Smith SC Jr, Lichtenstein AH, Svetkey LP, Loria CM, Wadden TW, Millen BE, Yanovski SZ. 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013 Nov 7. pii: S0735-1097(13)06029-4. doi: 10.1016/j.jacc.2013.11.003. [Epub ahead of print]
- Stone NJ, Robinson J, Lichtenstein AH, Bairey Merz CN, Lloyd-Jones DM, Blum CB, McBride P, Eckel RH, Schwartz JS, Goldberg AC, Shero ST, Gordon D, Smith SC Jr, Levy D, Watson K, Wilson PW. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013 Nov 7. pii: S0735-1097(13)06028-2. doi: 10.1016/j.jacc.2013.11.002. [Epub ahead of print]
- 2013 Risk assessment calculator.
Please note the conversion factor from mg/dl to mmol/l for lipid measurements is 38.67. 100mg/dl is equivalent to 2.586mmol/l.
Content updated January 2014