New AHA / ACC Cholesterol Guidelines – Controversial but not to be Feared

Last week four guidelines were released by the AHA and ACC. A tremendous amount of controversy surrounded the Cholesterol Guidelines as they deviated in fundamental ways from prior standards. The writers of the guidelines took a strict Evidence Based Medicine (EBM) slant, limiting extrapolation and thereby altering the traditional approach to cholesterol management. For example the format of all prior clinical trials did not specifically address cholesterol goals. Thus they were excluded from the guidelines. That does not, however, mean that it is wrong to continue to try to “get our patients to goal”. It simply means that in the strictest view of EBM, there is insufficient evidence to do so. The American Society for Preventive Cardiology (ASPC, of which I am Treasurer) and several other organizations endorsed the document. The National Lipid Association (NLA) did not. It is critical for practitioners to understand two things when trying to utilize this document as effectively as possible. First, the guideline was meant to be a living work, one that will be updated at regular intervals. Second, and perhaps far more consequential, it is essential that practitioners ardently adhere to a single paragraph from the guidelines which follows:

“Guidelines attempt to define practices that meet the needs of patients in most circumstances and are not a replacement for clinical judgment. The ultimate decision about care of a particular patient must be made by the healthcare provider and patient in light of the circumstances presented by that patient. As a result, situations might arise in which deviations from these guidelines may be appropriate.”

In sum, we most always remember that guidelines are just tools to help practitioners understand the most recent evidence in medicine. They are not laws. Clinical judgment must always reign supreme.

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