NOV 11, 2015 12:00 PM PST

Cholesterol Treatment Guidelines: Controversies and use in clinical practice

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  • Medical Director of Cardiac Rehabilitation and Stress Testing, Staff Cardiologist, Cleveland Clinic
      Michael Rocco, MD, is the Medical Director of Cardiac Rehabilitation and Stress Testing, Section of Preventive Cardiology, and a Staff Cardiologist, Section of Clinical Cardiology and Preventive Cardiology, in the Robert and Suzanne Tomsich Department of Cardiovascular Medicine. He also holds an appointment in the Section of Nuclear Cardiology in the Department of Molecular and Functional Imaging. He is board-certified in internal medicine, cardiology and nuclear cardiology. Dr. Rocco has a special interest in clinical cardiology, stress testing and cardiac rehabilitation, coronary artery disease, cardiac catheterization and the treatment of lipid disorders.

      Dr. Rocco did his undergraduate work at Georgetown University in Washington, D.C., graduating Phi Beta Kappa and valedictorian of his class. He received his medical degree from Duke University Medical Center in Durham, N.C., where he was inducted into the Alpha Omega Alpha Medical Honor Society. He took his clinical training (internship and residency) at Brigham & Women's Hospital in Boston. He became a Research/Clinical Fellow in Cardiology at Brigham & Women's Hospital and at Harvard Medical School. Dr. Rocco completed the Henry J. Kaiser Fellowship Program at Harvard University, Boston, where he trained in epidemiology, biostatistics and clinical study design.


    In November of 2013 the AHA/ACA jointly proposed new guidelines for the management of hypercholesterolemia, the first full update in over a decade.  The charge was to create evidence based recommendations, whenever possible based on randomized clinical trials and meta-analysis of such trials. The finished product proposed a major paradigm shift in management. Still emphasizing the importance of risk assessment for determining treatment initiation, four groups were identified that would benefit from moderate or high intensity statin therapy in order to achieve cardiovascular risk reduction. Recommendations based the decision regarding moderate or high intensity therapy on the level of cardiovascular risk balanced against risks of intensive therapies. Controversies included elimination of previously proposed and long accepted LDL-C and non-HDL-C treatment goals, a new tool for risk stratification in primary prevention populations and de-emphasis of non-statin therapies. The guidelines did offer an extensive review of cholesterol altering medications and their risks and benefits, expert opinion on how to deal with statin intolerance, recommendations for the use of biomarkers/noninvasive testing in risk assessment and promised swifter integration of new data into future guidelines. However, limiting recommendations to clinical trials also may limit therapeutic recommendations for individuals falling outside these four treatment groups. Concerns were raised about both over treatment and under treatment in certain populations. A careful review of the published statement can address some of the controversies but others still exist. Newer studies with conventional therapies and recently approved therapies may soon trigger a rethinking of the guidelines particularly relative to goals for therapy and combination therapies with statins. Objectives are to review the details of the 2013 guideline, highlight the weaknesses and strengths of the guideline and discuss utilization of these recommendations in current practice.

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