There’s much that’s familiar in the new American Heart Association guidelines to help clinicians manage cholesterol, the waxy, fatlike substance that can build up in arteries and cause heart attack and stroke. For one thing, they stress the power of a healthy lifestyle — plenty of exercise and leafy greens, absolutely no smoking — to control LDL (bad) cholesterol.
While HDL (good) cholesterol doesn't get much play, the growing trend in a “personalized” cholesterol approach does. In a nutshell, not all LDL numbers reflect the same risk of a dangerous blocked or hardened artery: Clinicians are encouraged to factor in risks such as high blood pressure, diabetes, smoking or a family history of heart disease in deciding which patients should be prescribed statins to bring down their LDL number. (The guidelines also highlight a few risk factors you might not have heard of: being South Asian, or, if you’re a woman, hitting menopause early or having had preeclampsia while pregnant.)
One of the biggest updates? The more aggressive use of statins is recommended, as well as the more extensive use of a newer class of drugs known as PCSK9 inhibitors, to more tightly control bad cholesterol for those with established cardiovascular disease.
In fact, the new guidelines are downright prescriptive for this highest-risk group. If you're in it, and if your bad cholesterol level is 70 or more — and yes, 70 is a lower threshold than you might have heard before — the new recommendations specify that beyond statins, you should also be given the low-cost generic drug ezetimibe at the maximum dose. If after four to 12 weeks, ezetimibe fails to get the job done, they say a PCSK9 inhibitor should also be prescribed.
“Compared to 2013 [guidelines], this is a very new recommendation that nicely integrates new clinical trial evidence,” says Seth Martin, M.D., a preventive cardiologist at Johns Hopkins Medicine who led one of the major clinical trials’ driving recommendations for those with established cardiovascular disease. While PCSK9 inhibitors work differently from statins, both types of drugs increase the function of LDL receptors on the surface of the liver, helping the organ to pull more of the bad cholesterol out of your bloodstream, he explains. While Martin notes that the “the big concern with respect to PCSK9” previously had been the cost, drugmakers recently cut prices of some by more than half, putting the drugs more in reach for larger numbers of people.
For everyone else, doctors are to rely on a matrix of factors, weighing your LDL score along with all those other factors that might make you more likely to suffer a heart attack or stroke. Such risk calculators have been updated to move more patients from low to intermediate risk.
When those calculators come back with a borderline answer, another major update comes into play: the newly recommended use of a coronary artery calcium (CAC) test for those with higher-than-desired cholesterol levels but less-than-conclusive cardiovascular risk status. The test, which costs about $75 to $100, works like a CT scan to spot “white spots in the arteries,” Martin explains. If you have zero visible white spots, you don’t have any cholesterol deposits that have led to calcification of the arteries. But if you do have a certain percentage of such plaque, you’ll be moved to the “intermediate risk” category, earning yourself a statin prescription.