Confusion About Guideline Recommendations Contributing to Suboptimal LDL Management in ASCVD Patients

The number of published guidelines with substantially different recommendations for the management of low-density lipoprotein (LDL) in patients at risk for atherosclerotic cardiovascular disease (ASCVD) is one reason for the suboptimal management of at-risk patients, according to a review of clinical practice guidelines published in the Journal of the American College of Cardiology.

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The review, which is based on proceedings from the ACC's LDL: Address the Risk Think Tank held last year, summarizes current guidelines for reducing LDL-related cardiovascular risk developed by the national Cholesterol Education Program Adult Treatment Panel, the International Atherosclerosis Society, the European Society of Cardiology/European Atherosclerosis Society, the Canadian Cardiovascular Society, and the American Association of Clinical Endocrinologists. It also touches on the 2013 ACC/American Heart Association Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults, which the review authors note, addresses "only a limited number of critical questions" and does not provide "comprehensive recommendations for the management of all forms of dyslipidemia."

In the face of such disparate guidelines, the review authors point out that many clinicians and patients still have questions regarding the new recommendations. Not only are clinicians seeking simple tools to help with guideline implementation, they also need more information regarding the management of patients not considered in one of the four statin benefit groups (ie. those with high lifetime ASCVD risk and those with complex dyslipidemias). Patients are questioning the implications of initiation of therapy with high-dose statins, the lack of specific numeric goals of the therapy, and the reduced monitoring of statin therapy by laboratory assessment. "Patients require a careful explanation of the risks of dyslipidemia and a better understanding of the benefits of lifestyle therapy as well as the risks and benefits of pharmacologic strategies for management of LDL-related risk," the authors said.

Moving forward, the ACC's LDL: Address the Risk initiative is using the outcomes from the Think Tank to develop more effective strategies and tools for clinicians and patients to assist in ensuring guideline-recommended therapy is being implemented. In addition, the authors recommend that professional societies work together in the near future to develop guidelines based on unified principles of treatment for reduction of ASCVD risk, high-quality evidence from large randomized clinical trials, as well as other types of research. In addition, the authors urge a focus on individualized care and special patient populations not included in current guidelines.

"Education of providers regarding the process of guideline development and strategies for integration of existing guidelines will be important to successfully manage high-risk patients," the authors note. "Clinicians and patients will benefit from the understanding that these recommendations serve only as a starting point for care of the individual patient. Clinical judgment and patient preference must play important roles in the therapeutic decision."

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