Concepts and Controversies: The 2013 American College of Cardiology/American Heart Association Risk Assessment and Cholesterol Treatment Guidelines

摘要

On 12 November 2013, the American College of Cardiology and American Heart Association (ACC/ AHA) issued clinical guidelines on cardiovascular disease risk assessment (1) and cholesterol treatment (2). The recommendations are intended to guide decision making but do not replace clinical judgment. We highlight the core concepts of the guidelines that rest on widespread consensus, discuss controversial aspects, and suggest a potential middle ground for clinicians and patients struggling with how to proceed in the midst of the controversy. Core Concepts Value of the Art of Medicine The new guidelines value the art of medicine in that they allow room for individualizing primary prevention on the basis of shared decision making between the patient and clinician. When one is considering whether to initiate a statin for primary prevention in adults with a low-density lipoprotein cholesterol (LDL-C) level of 70 to 189 mg/dL and an estimated 10-year risk for myocardial infarction or stroke of 5% or greater, the guidelines advise that patients and clinicians engage in a "risk discussion." Such a discussion can address potential benefits and harms of statin therapy, drug-drug interactions, and patient preferences. Along these lines, we previously suggested consideration of the "5 Ps" (3): preference, precision, participation, potency, and price (Table).