Amid growing public controversy over the Lipid Guidelines, it may be time to pause and reflect on what has been accomplished and what is likely to need refinement over time.
First, the big news is the move away from a singular focus on LDL levels, with an emphasis on target levels and using all means possible to achieve them. The lipid hypothesis is not being impugned, but we are realizing that pursuing targets at all costs may lead to the use of medications that are not known to benefit patients.
Second, there is an emphasis on proven medications. We have learned that not all medications that favorably affect lipids result in risk reduction for patients. So we can use lipids to understand risk, but just because a medication improves a lipid profile does not mean that it has reduced the risk of heart attacks or dying. So the guidelines moved away from LDL and emphasized the use of proven medications to reduce risk – and statins are the class that has been shown most conclusively to reduce risk. Moreover, they reduce risk regardless of the LDL level. Also, the trials tested the drug – not a strategy based on a target. So the guidelines de-emphasize non-statins, like ezetimibe, and emphasize the statin class.
Third, the guidelines direct attention to risk. There may be controversy over the risk calculator to use – and the threshold that makes it worth it to receive treatment – but the principle of being cognizant of the size of the potential benefit will endure. We will need to work out details over time, but ultimately the decision about whether treatment is worthwhile should reside with a patient who is informed about the risks and benefits. We do need to be sure we are accurately estimating risk and finding ways to communicate information about the decision to patients, but we should not impose a decision on patients. It is up to us to include them.
So the movement away from lab value, the emphasis on proven medications and the emphasis on treatment for those with the most to gain are terrific aspects of the guidelines. Now is the time to turn to implementation and tools. We do need to determine what is the best way to estimate risk and communicate it with patients. And most importantly, we need to learn how best to engage patients in the decision. But the guidelines have laid out some important principles to guide the development of these tools – and ultimately help us all to make wiser decisions about prevention.
In our enthusiasm to find flaws in the guideline, we should take time to reflect on what represents real advances. That’s not to say that we don’t need to invest in continuing to improve them, but sometimes it is worth taking a deep breath with new guidelines and appreciate what is good about them.