New ACC/AHA Guidelines: Current Lipid Management in Diabetes

In 2013, the American College of Cardiology (ACC) and the American Heart Association (AHA) released their joint guidelines for cholesterol screening and treatment. The new guidelines were developed in conjunction with the National Heart, Lung, and Blood Institute (NHLBI). ^{1, 2}

These guidelines replace the Adult Treatment Panel III (ATP III).

“There was supposed to be an ATP IV, but the government finally gave up on it and NHLBI took over. What’s new here is we looked at cardiovascular health in general, including stroke. We also added a new risk estimator that included research on white and black Americans. The most controversial part is abandoning an LDL number as a treatment goal,” said Robert H. Eckel, MD, an author of the guidelines and professor of medicine and endocrinology at the University of Colorado in Denver.

Changes and Limitations

The major change is the move away from targeted cholesterol levels to risk calculation. The ACC and AHA have published a risk calculator that predicts the 10-year risk for heart disease and stroke. If a person’s risk is 7.5% or higher, the guidelines recommend a tiered system of statins to reduce this risk. ^{2, 3}

One limitation the authors of the guidelines had to accept was only being able to use data from randomized, controlled trials as required by NHLBI.

“Doctors are used to treating to goals, so this is different, but the trials we used are not based on achieving certain cholesterol numbers. That does not reflect the way the trials were designed,” Dr. Eckel said

Lipid Management for Diabetes

“The guidelines are based on much stronger evidence. Everyone agrees that statins are the best way to lower LDL. The guidelines for diabetes say anyone with diabetes between age 40 and 75 should be on a moderate dose of statin. If someone has a 10-year risk over 7.5%, they should be put on more intensive statin therapy to reach a 50% reduced LDL goal,” explained Om P. Ganda, MD, director of the lipid clinic at Joslin Diabetes Center and associate professor of medicine at Harvard Medical School in Boston.

The new guidelines identified four groups who would benefit from statin therapy to reduce CV risk: ^{2, 4}

• Anyone with an LDL cholesterol level higher than 190 mg/dL
• Anyone aged 40 to 75 years with diabetes
• Anyone with CVD
• Anyone with at least a 7.5% on the risk calculator 

“With the new statin benefit groups, anyone with diabetes between age 40 and 75 automatically has a statin indication, even if they have no other risk factors,” Dr. Eckel said.

These are the basics for diabetes lipid management under the new guidelines: ^{1, 2}

• All patients aged 40 to 75 y ears without heart disease and with LDL less than 190 mg/dL will get a moderate-dose statin. The goal of treatment will be to lower LDL by 30% to 50%. A higher dose may be considered if the risk calculator goes above 7.5%.
• All patients aged 21 years or older with any CVD or LDL at or above 190 mg/dL receive treatment with high-dose statins. The goal of treatment is to reduce LDL by at least 50%.
• Intensive lifestyle management is recommended for everyone.