5 Steps to prevent Heart Disease

Sunday, May 4, 2014

Historic NLA meeting in Orlando going over new LIPID guidelines.

Posted 5-4-14

Grundy, Stone and V Brown were all on the first ATP I guideline committee 25 years ago.  Neil Stone was the new chairman of the ACA/AHA 2014 lipid guidelines that recently came out.  He received a good deal of criticism because he (the committee)  advised giving statins sooner at a 7.5% risk over 10 years.  He created a risk estimator that improves on the old Framingham risk calculator.
Dr. Neil Stone said the initial criticisms of his estimator have proven unfounded as well as the fact that 7.5% risk does not mean automatic statin but instead automatic discussion between the Doctor and the patient about the patients options.

If a patient is uncertain a CAC (Coronary Calcium Score) can then be done to see if a CAC 300 reclassifies the patient to a higher risk category.  

If the CAC is zero, then the patient can be reclassified to low risk and not go on statin for 5 years and then repeat CAC.  
Atorvastatin 20 mg is considered a moderate dose & could be advised to be given even with a very low risk of 5% over 5 years.  But Stone and committee decided to be conservative and put the cut off higher at 7.5%.

The NLA published a draft of it's own recommendations on Fri that was more patient centered than population centered to fill out some gaps of the ACA/AHA guideline.

CAC maven Dr. Matthew Budoff believes the cut-off to re-classify patients from intermediate risk to high risk should be CAC 100 or higher.
Budoff said if you have a CAC of 100 you have 10 fold increased risk of Cardiovascular event.

Both guidelines agree that 10 year risk should be replaced with lifetime risk till age 80.  A diabetic age 50 would have about a absolute lifetime risk of 60%.

Atorvastatin 20 mg is a moderate dose but if given over a longer period at an earlier stage progression of atherosclerosis can be stopped.

I believe rather than doubling Atorvastin if follow up lab does not reach threshold (as opposed to goals?) which would only decrease LDL-C by 6% more,
I believe adding wax matrix niacin 1,000 mg a day achieves 16% LDL-C reduction (As per COMPELL trial) and as with many combination models of treatment in medicine, lower dose meds with different actions causes less side effects especially for lifetime treatment.

NLA recommendations are not superior to ACA/AHA guidelines as the NLA is using more data other than Random Controlled Trials.  It tries to use more data to have more flexibility at the patient level.  Dr. Stone argued he used data before 1995 such as Helsinki when evaluating non-statin therapy.  He also used data after 2012 such as REGARD when evaluating the risk estimator.

Stone insists his guidelines state that the decision to start statin occurs only after a discussion of options with the patients. Dr. Stone said the media missed this point and misrepresented the guidelines in that regard as well as follow up lab work.

Both groups agree that non-HDL cholesterol should replace LDLc as a better predictor of risk.  I predicted that change in my Tubby Theory book from 2009.

Both groups agree that lifestyle changes should precede statin most of the time.  Mediterrannean diet was advised as the best and least restrictive as it allows a full range of food.  I think it is still restrictive as you have to move to the Mediterranean area to get the true non-stress life that is an important confounding co-variable.

However for weight loss, any diet the patient can stay on is the best diet.  

I think the guidelines need to warn patients of the reduced obese state.  Once you lose 10% or more weight on a 1500 calorie diet, you need to stay on the 1500 calorie diet the rest of your to maintain your weight loss.

See http://t.co/fQNDNVXe

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