New Analysis Supports 2013 ACC/AHA Cholesterol Guidelines

Percent LDL cholesterol reduction appears to provide incremental prognostic value over statin dose and attained LDL cholesterol levels in patients treated with a statin. However, the attained LDL cholesterol level does not appear to provide additional prognostic value over statin dose and percent LDL cholesterol reduction, thus supporting the 2013 ACC/AHA recommendations.

These data from a new analysis were presented at the American College of Cardiology (ACC) Scientific Sessions 2015.

“We were surprised with the results,” said study author Sripal Bangalore, MD, who is the director of the Cardiovascular Outcomes Group and an associate professor of medicine at the New York University School of Medicine. 

The 2013 ACC/AHA guidelines on the treatment of blood cholesterol recommend moderate- to high-intensity statins for patients with atherosclerotic vascular disease. However, the guideline departs from the traditional treat-to-target approach.  

Dr. Bangalore said there is no evidence to support continued use of specific LDL cholesterol and/or non-HDL treatment targets. He said current randomized clinical trial data do not indicate what the target should be. In addition, both magnitude of additional risk reduction with one target compared with another and the rate of additional adverse effects from multidrug therapy used to achieve a specific goal are unknown. 

Dr. Bangalore and his colleagues looked at patients in the TNT, SPARCL and IDEAL trials who were randomly assigned to statin therapy. The primary outcome of this investigation was major cardiovascular (CV) event. The researchers assessed incremental prognostic value by using a forward conditional Cox proportional hazards model. Two models were tested (Model 1: Step 1-Statin dose, Step 2-add attained LDL cholesterol levels at 3-month visit post randomization, Step 3-add the percent LDL cholesterol reduction from baseline; and Model 2: Step 2 and 3 were reversed).

Among the 13,959 patients included in this study, the percent LDL cholesterol reduction added incremental prognostic value over both statin dose and attained LDL cholesterol levels. However, attained LDL cholesterol level did not provide incremental prognostic value over statin dose and percent cholesterol reduction.

“The take-home message is that it is essential to check lipid values 3 months after initiation of statin to assess for percent LDL reduction as it had prognostic value. The reason we did this study is directly related to the 2013 ACC/AHA guidelines,” Dr. Bangalore told Endocrinology Advisor. 

“This has generated a lot of controversy by moving away from treat-to-target toward just recommending a moderate- to high-intensity statin. We therefore wanted to know if either achieved LDL level or percent LDL reduction provides prognostic value. Our study supports the guidelines.”

Kim Williams, MD, who is the president of the American College of Cardiology and the chief of cardiology at Rush University School of Medicine in Chicago, said this analysis has important clinical implications. He pointed out that evidence like this is vital because this has been such a controversial area. 

“It is a wonderfully designed study. It is remarkable that it comes up with the same conclusion,” Dr. Williams said in an interview with Endocrinology Advisor. “We need to keep looking at these markers. We now need to get this message out and make sure people see this is very important.”

Reference

1. Bangalore S et al. Abstract 914-04. Presented at: American College of Cardiology (ACC) 64th Annual Scientific Session & Expo; March 14-16, 2015.