Our clinical leadership wanted to update our readership on some large-scale and important updates to cholesterol guidelines to help support awareness. The 2013 ACC / AHA clinical guideline for cholesterol treatment and coronary disease prevention was recently updated to better integrate patient information data and improve atherosclerotic cardiovascular disease (ASCVD) risk assessment.
The guideline updates emphasize proper implementation of statin drugs and PCSK9 inhibitors considering a renewed focus on a 10-year ASCVD risk scoring system through patient data. Furthermore, emphasis on coronary artery calcium (CAC) scores and the ASCVD scoring system will help clinicians personalize treatment, prevention steps and management at the individual level by determining case-by-case risk scores that influence next steps.
Under the new 2018 guidelines, the ASCVD risk score will not prompt statin therapy but CAC scores may prove to be a “tie-breaker” in determining the statin drug use for individuals with an intermediate ASCVD risk score. The 10-year ASCVD risk scores derived from historical patient and population health information, however, will play a central role in determining the intensity of the management program, strategies and guideline implementation. For example, in certain cases drug therapy is most appropriate while other cases require simple lifestyle modifications for effective management and prevention.
The 2018 guidelines for cholesterol treatment and coronary disease prevention retained four major categories from the 2013 guidelines of patients with different management needs for whom statins may be appropriate:
- Primary prevention: that is, no clinical ASCVD or diabetes but LDL-C 70 mg/dL or higher and 7.5% or greater 10-year risk by the calculator
- No clinical ASCVD but with diabetes and LDL-C of 70 mg/dL or greater
- Secondary prevention: that is, clinical ASCVD without heart failure
- Severe primary hypercholesterolemia (LDL-C ≥190 mg/dL)
New Value Statement
A new aspect of the 2018 clinical guidelines for cholesterol treatment and coronary disease prevention is the assigning of a value to drugs for a given individual, or clinical circumstance. This Value Statement establishes the importance of considering drug costs when determining the optimal solution path. For example:
- Patients at very high risk of ASCVD received a low-cost value for PCSK9
- Patients at very high risk of ASCVD received a low-cost value for PCSK9 – Patients with familial hypercholesterolemia received an uncertain value compared to good cost value
According to the American College of Cardiology (ACC), the updated “guideline also sets out very specific recommendations for clinicians to discuss options with patients in the newly defined ‘very high risk of ASCVD’ category who still have LDL-C above 70 mg/dL after maximizing statin therapy.” For these patients, the guidelines suggest non-statin drug consideration, such as PCSK9 inhibitors and ezetimibe. For patients with further risk factors, such as hypertension, low HDL, etc. attaining an LDL value of less than 100mg/dL is particularly important.
Furthermore, and especially for higher risk individuals, the new guidelines establish low-density lipoprotein cholesterol (LDL-C) treatment targets as having increased decision-making influence in relation to statin drug use – and an increased focus on personalized care and patient and physician communication. The goal is to personalize the care discussion and avoid generic solution paths, ultimately leading to improved outcomes.
The Institute of Medicine (IOM) defines clinical guidelines as, “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” In a sense, clinical guidelines serve as evidence-based guidance derived from experienced clinicians who have navigated a variety of specific clinical circumstances through all-inclusive disease management protocol. Every individual’s disease and treatment options are unique to the individual’s body and experience, and therefore should be approached as such.
Coupling the recent cholesterol and coronary disease prevention guidelines with analytical insight helps identify the right individuals, engage them through the right outreach program and manage them with the right resources. More specifically, coupling the 2018 guideline updates with analytical insight improves ASCVD risk score accuracy, and helps to identify the specific clinical circumstance at hand – essentially providing a road map for that given circumstance.
Care providers looking to establish successful quality and cost control are implementing patient management via clinical guideline-driven strategies supported by proven healthcare practice and population data / health analytical insight.
To learn more about how our Poindexter analytics platform can support these efforts, please contact us here.