A Cardiologist’s Take on New Cholesterol-Lowering Guidelines

New clinical guidelines for cholesterol treatment could be a good thing for both physicians and patients, so long as they are used properly.

Unveiled last month at the American Heart Association’s 2018 meeting, the guidelines are intended to help physicians navigate the treatment of patients with high LDL cholesterol.  They aren’t perfect, as guidelines seldom are. For instance, only one patient participated on the committee responsible for the new guidelines, even though the guidelines will impact the lives of thousands of patients.  

But they are a vast improvement over the current standards, for two primary reasons:


  • They encourage a personalized treatment approach.  The guidelines recommend that physicians not only use the existing risk assessment calculator but also consider patient-specific factors.  Things like smoking, weight and hypertension, as well as risk factors such as family history and ethnicity, may now be incorporated more often into treatment decisions.  Determining a patient’s risk helps a physician identify a specific LDL target and the most appropriate therapy to reach that target.
  • They specify LDL targets and therapeutic approaches. The new guidelines cite LDL cholesterol targets, which did not appear in the 2013 guidelines.  These targets vary based on patients’ risk level. So does the progression of therapeutic approaches designed to meet them.  They also help physicians measure progress toward patients’ decreasing cardiovascular disease risk.


And, for the first time, the guidelines acknowledge the value of innovative PCSK9 inhibitors for certain patients.  Research demonstrates that PCSK9 inhibitors can lower stubborn LDL cholesterol, and recent price decreases could improve their accessibility.

For these reasons, the guidelines are a welcome resource for cardiologists and their patients.  But I’d offer a word of caution. All parties should remember the guidelines are just that—guidelines.  In particular, I’d remind policymakers, health plan officials and physicians that:

  • Guidelines do not replace physicians’ clinical judgement.  Rather, they help inform the patient-physician conversation—one that also includes anticipated benefits, adverse reactions and drug interactions.  Patients and their physicians together should agree upon a course of treatment after considering all factors.
  • Guidelines should not be twisted to restrict access to treatment.  Despite physicians’ expertise and knowledge about their patients, national data show nearly half of insurers initially deny coverage for PCSK9 inhibitors.  Some patient advocates fear that insurers will use the new guidelines to further restrict access.  

Cardiologists are fortunate to have both innovative medicines and, now, clear-headed guidance, at their disposal.  I trust my colleagues and I feel equipped, now as much as ever, to have personalized, contextualized conversations with our patients about health history, risk factors, therapeutic options and an individualized, LDL-lowering treatment plan that works best for them.


Dharmesh Patel, MD, is a cardiologist at Stern Cardiology Foundation in Southaven, MS, whose primary focus is the prevention of heart disease. He also serves as president of the Partnership to Advance Cardiovascular Health (PACH), which seeks to advance public policies and practices that result in accelerated innovation and improved cardiovascular health for heart patients around the world.


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