We are on the cusp of the Fourth Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel IV). As internal deliberations continue, it’s a good time to consider abandoning cholesterol targets as the central focus of the recommendations.
Statins are the lipid lowering drugs with the strongest evidence of benefit (some medications, like ezetimibe, have yet to be shown to improve patient outcomes). Statins reduce risk across the spectrum of LDL values. The first generation drugs reduce risk about 20% and the higher potency and high dose statins reduce it by about another 15%. If you bluntly target LDL, you will be:
- treating some patients with low risk (those without other risk factors and LDL that is not exceptionally high)
- neglecting some high-risk patients (those without elevations in LDL but with many other risk factors).
Maybe it is time to decide about treatment based on risk. No trial has ever tested the target strategy—the major trials tested fixed doses of drugs—so it is not that we are abandoning RCT evidence. Rod Hayward and I have written an open letter to the Guideline writing committee in Circulation: Cardiovascular Quality and Outcomes.
What do you do in your practice? How would you recommend that the committee tackle this issue?