Episode 221: Finally getting the cholesterol guidelines right – almost

In episode 221, James, Mike and Tina delve into the newly released 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults. We discuss the highlights of the guidelines and how it appears the guidelines are, low and behold, actually following the evidence.

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Here comes another "shock"

ESC guidelines on hypertension 2013: <140/90 is the new goal for all subgroups! And treatment isn't always necessary betwenn 140 and 160 systolic RR..... unfortunately, they are promoting sartans as first line opton, and even aliskiren as a second line agent.... you can't have it all....

link: http://eurheartj.oxfordjournals.org/content/34/28/2159.full.pdf+html?sid=5dbe9b90-8a6d-4969-b3e0-76d1d905ed05

still love your podcast.... what's the reason you don't talk more about in-hospital-care? I would like to hear that....

greetings form germany


Isolated high LDL

Hi guys,

Thanks for the nice update of the new American guidelines. Glad to hear that evidence is starting to prevail. I do want to take slight issue with your discussion of one of the subgroups recommended for statin therapy by the guidelines, i.e. those with high LDL levels. Mike made the point of using global risk stratification as opposed to just the LDL level (which James rightly pointed out isn't part of our standard calculators), however my impression is that the guidelines are targeting those with familial hypercholesterolemia, who may have isolated high LDL without any other obvious risk factors, and for whom the risk calculators are probably underestimating their lifetime risk. (According to the 2006 CMAJ review of FH linked below, risk of CAD by age 60 is 30-60%.) That said, without a positive family history or tendon xanthomas (or other weird and wonderful clinical signs), I agree that it's tough to justify treatment based on LDL level alone. 


Also, thanks for pointing out the variability in the outcomes being predicted by various CV risk calculators. When I started using my EMR and its built-in "Framingham calculator," I was surprised at how high the predicted 10 year risk was for some of my patients. After a little digging, it turned out the calculator included a lot more than just the usual "hard" outcomes. I'd urge everyone using a similar EMR-based calculator to either look into what you're actually calculating, or use a specific calculator that you trust. 




1. Yuan et al. CMAJ - 2006 - http://www.cmaj.ca/content/174/8/1124.full.pdf.