2026 ACC/AHA Dyslipidemia Guideline Review: Getting to the Heart of the Evidence - Frankly Speaking Ep 497

[music] Welcome to Frankly Speaking about Family Medicine, a CME podcast series where each week we translate today's late-breaking clinical research and news into tomorrow's practice. I'm Dr. Frank Domino, Professor in the Department of Family Medicine and Community Health at the University of Massachusetts Chan Medical School and Editor-in-Chief of the 5 Minute Clinical Console. This podcast is brought to you by Primette. Hi everyone, this is Frank Domino. What's better than spending three days with your peers connecting over how you practice and your practice challenges? Let's do that together at the Primette East, this October 7th through 9th, at the Rhode Island Convention Center in Providence, Rhode Island, where you can earn up to 30 CME or CE credits. I'm serving as the course chair for this conference, which is designed specifically for primary care clinicians. Dr. Rachel Rubin will be joining us for her keynote address on hormone replacement therapy and I'll be presenting Frankly Speaking Live so you can be part of the podcast in person. As a Frankly Speaking listener, you can register for $50 using the code F-R-A-N-K-L-Y at primette.com/east. You are having lunch with your colleagues in between bites of your sandwich. One of your peers asked your opinion of the new cholesterol guidelines. She states, "Seems like they want everyone on a statin and to make their LDL go as low as possible." Is that safe? You wonder the same thing. Hi, this is Frank Domino. And joining me today is Dr. Robert Baldor, professor in founding chair from the Department of Family Medicine at the UMass Chan Medical School, Bay State, located in Springfield, Massachusetts. Hi, Bob. Hi, Frank. I got to tell you, these guidelines are the American Heart Association and these cardiologists have been busy. These were just published a few weeks after their hypertensive guidelines. And so some of this is going to be a little overwhelming. Can you help summarize what if the key take-home messages here on these guidelines? I will be happy to. So truth be told, covering and viewing all this data was an overwhelming task. And the first thing you need to know is that the vast majority of authors of this new guideline are cardiologists. In fact, no one who does primary care was included in the panel of physicians and providers who put together this new guideline. So let's cover the top key points that were made by the guideline. And then I'll discuss the best evidence about them. And then I'm going to drill down on the recommendations that are a bit at best controversial, but mostly just expert opinion. And to give you an example, about 20% of the guideline is based upon high quality evidence. And at least 50% is based on expert opinion. So the first recommendation they suggest are what they call early intervention and primordial prevention, which sounds bizarre. They recommend, initially, to look at screening at age 11 and then repeat every five years. They especially recommend aggressive screening. The patient has a strong family history of premature cardiovascular disease. And then it's cardiovascular events before the age of 45. But they also note that one in 250 children without a family history might have elevated total cholesterol and LDLs. This recommendation is just expert opinion. The ACC thought this was a good idea. There's no data supporting this, no data showing that screening prevents cardiovascular disease, no data to guide us at all with what to do if the numbers are abnormal. It should be noted that the US for and of services task force, the American Academy of Pediatrics and the American Academy of Family Medicine recommend against this screening as there is no evidence that screening and initiating treatment has improved outcomes. And it may include harms, including the cost of testing, the costs of medication, and the psychological impact of telling a young child they might have a diagnosis and need to take a medication every day. Now the American Academy of Pediatrics has a different universal lipid screening policy. They suggest that you can screen between the ages 9 and 11 and between 17 and 21, but they note overtly that this is expert opinion and they base this opinion on 20/11 research. So the American Academy of Pediatrics says it's okay, but they are transparent in that it's just an opinion. What are the risks of doing this to children? Well a systematic review of 1,400 children found no association between statin use and slower growth in development. So that's good news. We know that if you put a child on a statin, you won't necessarily alter their growth, but a 20 year study found that females older than 10 treated with statins had higher BMI and higher weight. And finally, what do you do with an elevated LDL on a child? There's no trial data that shows that this has been useful in anyone in this age range. The next recommendation is to use the Prevent Risk Equation that replaced the pool cohort equation. And the Prevent A/S EVD risk calculator is more accurate at predicting risk and will continue to be refined over time. It's based on a large set of cohort studies and really is helpful in determining an individual's risk for primary prevention of cardiovascular outcomes. So I actually agree with it. You should use this as a risk tool to help define risk. The problem is that they've lowered the threshold to start statins. They call less than 3% okay and recommend treatment with lifestyle interventions. Through to five, they recommend that patients more consider a lipid-lowering medicine. And this is using small beta sets. And if there's a benefit of starting a statin in this pot and that if someone with a 3% to 5% risk, it's less than 1% in lowering cardiovascular outcomes. They call intermediate risk 5% to 10% where lipid therapy should be considered. In over 10%, they recommend strongly to start lipid-lowering with an LDL-C less than 100 milligrams per deciliter. They feel strongly that if you have a history of diabetes, chronic kidney disease or HIV, you should be started on a statin regardless of your prevent score. Again, where did they come up with these thresholds? Well, 80% of it or so comes from expert opinion. There was one composite review article from 2022 that reported some of the support for these thresholds, but the vast majority are not found in medical evidence. They're just opinion. The US preventive services task force and the night skyd lines from Europe report that you should consider initiating statins for primary prevention once the risk score is over 10%. Wow. You know, I certainly agree that to prevent risk score is an improvement of what we've been using in the past. But how do we really use these scores? It's just puzzling to me. Well, my take on it is for primary prevention, initiate treatment when the prevent score gets over 10 with a goal of getting an LDL below 100. I think we have great data that supports that. They're also talking a bit about using non-HDL treatment goals, but again, I can find a great deal of data that that has any evidence base. For secondary prevention, they're stating that you should get the LDL, both a 50% reduction from baseline and getting the LDL below 55 milligrams per deciliter. Thanks. In patients at very high risk for ASCVD, I guess that's okay. There's only one industry-sponsored randomized control trial with this goal and folks from South Korea. And the benefit was slight. So this makes me wonder, why would they take such a strong stance again without a great deal of evidence? And it makes me worry that there's some industry influence that something new is coming down the road that's going to have an impact on cholesterol in particular lowering LDLs. Frank, I hear you on that one. I mean, certainly for secondary prevention, I agree with perhaps with being more aggressive as the primary prevention group. I struck with it at a younger and younger ages. But they also talked about the test beyond lipid testing as well with this guideline, right? What can you talk about though? I think it was APO B, I believe. Yes, so the way. There is APO, APO protein B, lipoprotein A, and HSCRP testing. These are considered risk enhancers. And back in April of this year, Alan Erlock did a great podcast on the lack of data supporting the HSCRP recommendation. So let's look at the other tests. But they're, like I said, called risk enhancers, meaning that if they're negative, their prevent score still accurately predicts their risk. What if they're positive, their risk may be increased, but we don't know by how much. We also are going to do a complete focused, LAPO protein A podcast coming up this later this year that I think you'll really enjoy because it drills well down on it. The other test they've recommended is getting a coronary artery calcium score. And we recommend getting this test when you need to refine risk. So how best to use this test? Well, this is a test for a patient who's in that intermediate range. I think about someone who's prevent score is maybe 7.8 or 8.5 and you say, "Ginger in that gray area where you might benefit from a statin." And the person's somewhat resistant, getting a calcium coronary calcium score can help you determine how their risk might change. So I find this is a good place to use that test. The coronary artery calcium score of zero rules out the need for statins in intermediate risks, but a score over 100 implies an increased risk and with support starting a statin. What to do if the score is between 1 and 100? Moved any news? You know, I like all of these things, right? It's pretty clear to me. You know, a low risk, no problem. High risk, no way. We got the tree in the between. What are we doing with a lot of this stuff? It's still struggles. They also talked about triglycerides though, right? Is that the other part of their lipid management here? Yes, in addition to measuring, apobie and lipo-a and HSCRP, they think we should be getting aggressive about hyper triglycerideemia. So if you find hyper triglycerideemia on a lipid panel, there's a number of things you should consider. My first is to repeat the test and guarantee that the patient's been fasting for eight hours. It's still elevated. You need to take a very careful history because the most common causes of elevated glycerides are undiagnosed or poorly controlled diabetes, a very high carbohydrate diet, and/or alcohol abuse. Other causes include metabolic syndrome, hypothyroidism, chronic kidney disease, and certain medications like atypical anti-psychotics, beta-barkers, thiazides, oral estrogens, corticosteroids, HIV, protease inhibitors, isotrotonin, bile acids, sequestrants, and finally pregnancy. All of these should be considered and tested for before beginning an aggressive treatment. So assuming the triglycerides are truly elevated and are not secondary, the treatment options are lifestyle. Reduce adage sugar, reduce alcohol, reduce saturated fat, aerobic and resistance training exercises, and weight loss of 5-10% if overweight or obese. Also, LDL from the lipid panel is a not a measured result, but it's a calculated result that we typically get from the total cholesterol and HDL levels and the triglyceride level. So you cannot use an LDL from some of the high triglycerides unless you order a direct LDL where you start using the non-HDLC measure. What about treatment? For adults with severe hyper triglycerideemia, a fasting level greater than 500 that fails dietary interventions, fabric acid levels like phenylfibrate can be considered. Wow, a lot of them are on triglycerides. Well, let's wrap this up, Frank. What about folks who are at high risk but cannot still get to their LDL goal or other agents that are out there now? Yeah, so they do recommend that we consider using a drug like azetamide or PCS. It's an SK9 inhibitor for patients who are at high risk and cannot make their LDL goal. Now, it's important to note that these two drugs, azetamide and PCS, SK9 inhibitors of those two, the latter is the most potent, but two large clinical trials have demonstrated that there's no difference in either of these classes of meds on outcomes like major adverse cardiac events, amy stroke or all cause mortality. So if your maximum statin and dietary changes in exercise and you're still not a goal, certainly try azetamide first because it only runs $9 a month while the PCS, SK9 inhibitors are well over $500 a month. So what's the bottom line here? Screen patients who you feel at risk, the US preventive services task force recommends starting at age 40, noting that there's insufficient evidence to start screening before then. Use the prevent risk calculator to determine risk for primary prevention best evidence supports starting a statin when the 10 year caria prevent risk is over 10% and have a patient centered discussion between 7.5 and 10%. For someone in that range, if they want further information, obtain a coronary artery calcium score and as for HSCRP, ABOB and LIFOA as risk-inning answers, use them sparingly. Until we want more data that shows there's benefit from testing and decreased adverse outcomes. Thank you Frank. This is really a well nice summary. Practice pointer. In contrast to the American College of Cardiology American Art Association, Dislippidemia Guidelines, best evidence supports starting screening with lipid testing at age 40 and thoughtfulness about managing patients with risk scores between 7.5 and 10. Join us next time when we have a special guest, Dr. Rachel Rubin, who'll be talking to us about the management of menopause. 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