Features January 2014 Issue

New Guidelines Change Approach to Heart Disease, Stroke Prevention

The focus is shifting from reaching targets to lowering risks.

You may be hearing more from your doctor about your overall risk for heart disease and stroke in the months ahead, and a little less about reaching specific goals. Your blood pressure, cholesterol levels and other risk factors are still important, but the American Heart Association (AHA) and the American College of Cardiology (ACC) are saying they need to be considered as part of your overall cardiovascular risk profile, rather than isolated targets.

New stroke and heart disease prevention guidelines use blood pressure, diabetes and other factors to assess risk.

The AHA and ACC issued long-awaited guidelines for heart disease and stroke prevention near the end of 2013. The new guidelines were essentially divided into four categories: obesity, cholesterol, risk assessment and lifestyle. But the risk calculator and the likelihood that more Americans could be prescribed statin therapy based on their risk assessment have raised questions about the guidelines.

“This represents an enormous shift in policy, away from treating to target goals to target risks,” says Steven Nissen, MD, chairman of the Robert and Suzanne Tomsich Department of Cardiovascular Medicine at Cleveland Clinic. “We need to take some time to evaluate everything. We want to make sure we’re doing the right thing.”

Dr. Nissen and other leading health experts have expressed concerns that individuals who might otherwise be considered at low risk for heart disease and stroke will see their risk assessment increase under this new method of risk evaluation. “This would have more people being treated with more intensive doses of statins,” Dr. Nissen says. “This is a huge change, and it’s very complicated. We’re going to need some time to study this further.”

Assessing risk
At the heart of the new guidelines is a new risk calculator that takes into consideration criteria such as age, gender, race, total cholesterol, HDL-cholesterol, systolic blood pressure, blood pressure treatment, diabetes and whether you smoke. By plugging this information into an online calculator, a person’s 10-year risk and lifetime risk for heart attack or stroke can be determined. The calculator can be found at http://my.americanheart.org/cvriskcalculator.

The guidelines call for a person with a 7.5 percent or higher risk for heart attack or stroke to be treated with statins, cholesterol-lowering drugs. However, Dr. Nissen suggests that the new calculator may overstate the risk of many people. As a result, statins could be prescribed to people who won’t see much of a benefit to taking the medications.

Members of the committee that drafted the guidelines acknowledged the risk of overestimating risks in some populations. They also said they will continue to evaluate the risk-assessments methods and make changes if any are warranted.

Cholesterol guidelines
One of the reasons the guidelines prompted such concern upon their release in November 2013 was that they marked a substantial change in determining who should be taking statins. The 2002 federal guidelines suggested that statin therapy be prescribed to people with a 10-year risk of heart disease that was equal to or greater than 20 percent. The new guidelines set the minimum risk warranting statin use at 7.5 percent or greater.

The new guidelines also include stroke risk, while the previous recommendations considered only heart disease. Also new to the recently released guidelines are recommendations for African-Americans, who face higher stroke and heart attack risks.
Just how the AHA/ACC guidelines affect your treatment in the months ahead remains to be seen. Though the new risk calculator takes several risk factors into account, there are still target cholesterol levels recommended by Cleveland Clinic and other institutions. They include:

- LDL (“bad”) cholesterol of less than 130 mg/dL, or less than 100 mg/dL if you have  diabetes or other serious risk factors. For individuals with serious heart or vascular disease, Cleveland Clinic recommends an LDL target of less than 70 mg/dL
- HDL (“good”) cholesterol of more than 45 mg/dL
- Total cholesterol of 100 to 199 mg/dL
- Triglycerides of less than 150 mg/dL.

Obesity as a disease
One of the other key components of the AHA/ACC guidelines is a strategy of managing and treating obesity as a disease. Physicians are urged to actively help patients achieve and maintain a healthy body weight. Individuals are urged to calculate their body mass index, a score that incorporates a person’s height and weight. A score of 30 or higher indicates obesity, and the guidelines suggest that an obesity diagnosis warrants treatment.

Dr. Nissen says he supports the concept, but notes that other than urging diet and exercise, there are very few treatments at a physician’s disposal. “It’s a good idea, but the only real obesity treatment is bariatric surgery,” he says. “We haven’t had a lot of tools to help people.”

As part of that effort to control obesity, the new guidelines stress a diet centered around fruits, vegetables, whole grains, low- and non-fat dairy products, poultry, fish, nuts, with little or no red meat and sugary foods.

The healthy lifestyle strategy also includes smoking cessation and exercise of at least 30 to 40 minutes a day, three or four days a week. Exercise can even just include brisk walking, though a variety of physical activities that include aerobic exercise, resistance training and balance exercises is strongly recommended for older adults in particular.

The final word
While healthcare experts debate issues such as risk assessment and statin therapy, individuals are urged to pay attention to their controllable risk factors, such as blood pressure, cholesterol, blood glucose levels, weight, activity levels, smoking and stress. And no matter what changes are made to the risk calculator and the definition of “high-risk,” cardiovascular care will always come down to patients working with their doctors and taking charge of their health.

“The takeaway message is that individualized care will always be necessary,” Dr. Nissen says.

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