Target cardiovascular risk rather than cholesterol concentration

BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f7110 (Published 27 November 2013)

Cite this as: BMJ 2013;347:f7110

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Harlan M Krumholz, Harold H Hines Jr professor of medicine

Author Affiliations

harlan.krumholz@yale.edu

New American guidelines are a brave and wise departure from current practice

The recent American “Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults” heralds a new era in the prevention of atherosclerotic cardiovascular disease and stroke by focusing on reducing risk and abandoning cholesterol concentrations as targets.1 The new guidelines indicate that once lifestyle interventions have been exhausted drugs should be started on the basis of patient risk, that only those drugs known to reduce risk should be used, and that a singular focus on cholesterol concentrations should be abandoned.

This tectonic shift in prevention breaks with decades of recommendations stretching back to 1988, when the National Heart, Lung, and Blood Institute released the first US guidelines, which established clear thresholds for starting lipid lowering drugs and goals for treatment.2 Moreover, it is a marked departure from the European Society of Cardiology guidelines, published two years ago, which strongly endorse low density lipoprotein cholesterol (LDL-C) concentrations as targets for drug treatment.3

Clinicians and the public may find the new recommendations jarring. Doctors are taught about targets, tested in examinations about them, and may be evaluated and even paid according to their patients’ lipid concentrations. Academics make careers that are founded on studies to investigate how best to help patients reach salutary …