Lifestyle¹

1. The new lifestyle guidelines do not endorse a particular diet.

While the new lifestyle guidelines do not identify one diet as clearly superior to the others, the statements clearly endorse a pattern of eating consistent with the Mediterranean Diet or the DASH diet. Most importantly, the new guidelines do not endorse the traditional low-fat diet approach.

2. The new lifestyle guidelines do not strongly endorse reduction in sodium intake.

While the new guidelines did not find strong evidence for targeting a particular level of sodium intake (advice to restrict sodium intake to 2400 mg/day or furthering lowering to 1500 mg/day is described as "desirable" and given level of evidence B [moderate]), the guidelines strongly recommend an overall reduction in sodium intake (level of evidence A [strong]). A good goal mentioned in the guidelines is a reduction of 1000 mg/day which is achievable by most persons and if implemented in a population can have a dramatic impact on reducing CVD events.

Obesity²

1. The definition of overweight has changed.

The new obesity guidelines did not change the definition of overweight, which continues to be characterized by a BMI of >25.0 – 29.9 kg/m². However, in the past clinicians were advised to begin treating the overweight condition when two or more comorbidities were additionally present. This requirement has now been reduced to just one other comorbidity, and this comorbidity can be a concomitantly elevated waist circumference (indicating visceral adiposity). The cutoff for waist circumference is 40 inches or more for a man and 35 inches or greater for a woman, identical to the definition of the metabolic syndrome. However, the clinician must remember that certain ethnic groups have lower cutoff points, for example South and East Asians. Importantly, the new guidelines recommend regular (at least annually) assessment of waist circumference in overweight and obese individuals.

2. Select patients are candidates for short courses of intensive behavioral therapy.

On the contrary, the new guidelines recommend more widespread use of intensive behavioral interventions (ideally consisting of at least 14 sessions within a six month period) for overweight and obese patients. The best therapy for helping patients lose weight is behavioral counseling providing advice on how to increase physical activity and reduce calorie intake for at least six months or longer as part of an on-site, high-intensity program with a qualified healthcare provider. This can be accomplished in either a group session or in individual sessions. The Centers for Medicare & Medicaid Services (CMS) has indicated that Medicare/Medicaid will reimburse for intensive behavioral therapy for obesity. For continued weight loss maintenance, the guidelines recommend a high-intensity weight loss program for at least 1 year.

Cholesterol³

1. All patients with a 10-year CVD risk of 7.5% or higher, and most patients with 10-year CVD risk of 5.0% or higher, should be treated with a statin.

The new cholesterol guidelines represent a clear shift away from a treat-to-cholesterol approach to a treat-to-risk approach. Under the new guidelines, patients with a calculated 10-year CVD risk of ≥7.5% should be closely considered for statin therapy. Those with a 10-year CVD risk of ≥5.0% and at least one other additional risk condition should also be considered for statin therapy. However, in various media outlets it has been reported that all such patients should be treated with statins. This was not the intention of the guideline committee.⁴ We recommend readers closely examine figure 4 in the cholesterol guidelines, which should be considered the key figure from the guidelines (not the commonly presented figure 2). Patients meeting the above criteria should engage in a so-called "risk discussion" with their physicians and make a personalized decision about starting statins. Many patients who have an elevated risk based on their age alone will decide (in concert with counseling from the physicians) not to start a statin. The risk calculator is useful for identifying patients where there is net clinical benefit for use of a statin; however, it is not the risk calculator, but the physician who prescribes the statin.

2. There is no longer a role for rechecking lipids values in patients on statin therapy.

While the new guidelines dispensed with lipid targets, there is still a role of rechecking lipid panels on statins. This is commonly misunderstood. Multiple studies have shown poor compliance with chronic medications like statins, with poor adherence to therapy associated with poor outcomes. A lipid panel should be rechecked in 4-12 weeks after initiating therapy, with additional checks at three to 12 month intervals "as clinically indicated". The goal of these rechecks to assess for the "anticipated therapeutic response" to statin therapy. An insufficient therapeutic response (<30% LDL-C reduction on a moderate intensity or <50% LDL-C reduction on a high intensity statin) is reason to review barriers the patient may have for achieving adequate adherence, or if adherence is optimal or tolerability a reason for insufficient response, consideration of possible non-statin therapies (as discussed below).

3. There is no role for non-statin therapy at any level of LDL-C.

The new guidelines clearly — and appropriately — decreased the role of non-statin therapy in primary prevention given the lack of proven clinical benefit beyond statin therapy. The new cholesterol guidelines are for the most part statin guidelines, and most patients will achieve an LDL <100 mg/dL with appropriately intensive statin therapy. However, there continues to be a role for add-on non-statin therapy in patients with presumed familial hyperlipidemia identified by a baseline LDL >190 mg/dL and in high-risk patients (those with established CVD and in patients with diabetes) who do not have the anticipated therapeutic response to statins (either statin intolerance or <50% LDL-C reduction on statins). Clearly the prescription of a non-statin therapy is an issue where clinical judgment is particularly important and expectations (or lack thereof) should be clearly discussed with the patient.

Risk Prediction⁵

1. The new risk algorithm overhauls the Framingham Risk Score, incorporating new risk markers into the calculation of 10-year CVD risk.

After years of anticipation, and voluminous research in novel areas of risk prediction, the new risk calculator arrived looking much like the Framingham Risk Score. The exact same traditional risk factors are included. Obesity, family history, and other novel biomarkers are not included. What did change? Instead of reliance exclusively on the Framingham Heart Study, four cohorts encompassing a much larger sample size to ensure greater precision of estimates were used to derive this new calculator. There is now a separate equation for African-American patients. In addition, nonfatal and fatal stroke is added to nonfatal and fatal myocardial infarction to encompass overall atherosclerotic cardiovascular disease (ASCVD), which is a more clinically relevant composite outcome than past risk scores which focused on coronary heart disease risk alone. Finally, the new risk algorithm also allows for calculation of lifetime ASCVD risk, particularly recommended in younger and middle-aged persons where short-term risk may be low, but lifetime risk high; this would presumably be a potent motivator for the patient to improve adherence to lifestyle modifications. It remains to be seen if this new risk score has improved discrimination and calibration compared to prior risk scores. It is also unclear if this risk algorithm will lead to more personalized — or via a smaller intermediate risk group — less personalized risk predictions⁶.

Hypertension (JNC-8)⁷

1. Older patients ≥60 years old with treated systolic blood pressure <150 mmHg should have the intensity of anti-hypertensive therapy reduced.

The new hypertension guidelines have loosened the blood pressure target for older patients >60 years old to <150/90. However, this does not mean that older adults who presently have blood pressure <140/90 on multiple agents need a reduction in therapy. The guidelines specifically include a corollary recommendation that states that "if pharmacologic treatment for high BP results in lower SBP (eg, <140 mmHg) and treatment is well tolerated and without adverse effects on health or quality of life, treatment does not need to be adjusted."

2. The new JNC8 hypertension guidelines represent consensus recommendations, and are endorsed by major cardiology organizations.

The Joint National Committee 8 (JNC 8) was originally commissioned by the NIH/NHLBI to produce new hypertension guidelines. However, the NHLBI passed this responsibility to the AHA and the ACC in 2013. The JNC 8 writing committee did not wish to wait for AHA/ACC approval, and in fact believe hypertension to be more of a primary care issue rather than a cardiology issue, and pushed ahead with the recent publication of their long-awaited guidelines. It is clear that not all members of the JNC8 committee are fully pleased with the final document. A minority report pointed out concerns regarding the newly recommended higher threshold for BP treatment initiation, as this could potentially result in poorer blood pressure control overall and even a possible reversal of the gains in recent decades made in CVD risk reduction⁸. Moreover, the same week the American Society of Hypertension (ASH) jointly with the International Society of Hypertension (ISH) released their new guidelines⁹ upholding the prior recommendations for a goal and treatment initiation level of blood pressure in those <80 years of age of 140/90 mmHg, consistent with the most recent guidelines of the European Society of Hypertension.¹⁰ The AHA and the ACC have issued a "scientific advisory"¹¹ on the treatment of hypertension, and likely will produce their own hypertension guideline in the future.

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References

1. 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. [Epub ahead of print].
2. Jensen MD, Ryan DH, Apovian CM, Loria CM, Ard JD, Millen BE, Comuzzie AG, Nonas CA, Donato KA, Pi-Sunyer FX, Hu FB, Stevens J, Hubbard VS, Stevens VJ, Jakicic JM, Wadden TA, Kushner RF, Wolfe BM, Yanovski SZ. 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. J Am Coll Cardiol 2013. [Epub ahead of print].
3. 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. [Epub ahead of print].
4. Martin SS, Blumenthal RS. Concepts and Controversies: The 2013 American College of Cardiology/American Heart Association Risk Assessment and Cholesterol Treatment Guidelines. Ann Intern Med 2014. [Epub ahead of print].
5. Goff DC Jr, Lloyd-Jones DM, Bennett G, O'Donnell CJ, Coady S, Robinson J, D'Agostino RB Sr, Schwartz JS, Gibbons R, Shero ST, Greenland P, Smith SC Jr, Lackland DT, Sorlie P, Levy D, Stone NJ, Wilson PW. 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013. [Epub ahead of print].
6. Blaha MJ, Blumenthal RS. Risk factors: New risk-assessment guidelines-more or less personalized? Nat Rev Cardiol 2014. [Epub ahead of print].
7. James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, Lackland DT, Lefevre ML, Mackenzie TD, Ogedegbe O, Smith SC Jr, Svetkey LP, Taler SJ, Townsend RR, Wright JT Jr, Narva AS, Ortiz E. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA 2013. [Epub ahead of print].
8. Wright JT, Fine LJ, Lackland DT, et al. Evidence supporting a systolic blood pressure goal of less than 150 mm Hg in patients aged 60 years or older: The minority view. Ann Intern Med 2014.
9. Weber MA, Schiffrin EL, White WB, et al. Clinical practice guidelines for the management of hypertension in the community: a statement by the american society of hypertension and the international society of hypertension. J Clin Hypertens (Greenwich) 2014;16:14-26.
10. Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J 2013;34:2159-219.
11. Go AS, Bauman M, Coleman King SM, Fonarow GC, Lawrence W, Williams KA, Sanchez E. AHA/ACC/CDC Science Advisory: An Effective Approach to High Blood Pressure Control A Science Advisory From the American Heart Association, the American College of Cardiology, and the Centers for Disease Control and Prevention. J Am Coll Cardiol 2013. [Epub ahead of print].

Keywords: Guideline

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