Letter to AACE members about AHA and ACC guidelines

Thursday, November 21, 2013

Dear Members,

The American Heart Association (AHA) and the American College of Cardiology (ACC) have issued new guidelines for the management of Cholesterol and Lifestyle Management to reduce CVD. The AHA, ACC and The Obesity Society (TOS) have issued new guidelines on the management of Obesity. The AHA, ACC, and the Centers for Disease Control and Prevention issued guidelines on Hypertension.

AACE was asked to review and endorse the Obesity and Cholesterol guidelines. After careful consideration by the appropriate scientific committees of our organization, AACE declined to endorse these new Cholesterol and Obesity guidelines. There are multiple reasons for this decision, including principally the incompatibility of these new guidelines with our existing guidelines. Additionally, there are questions and concerns regarding the scientific basis for these new guidelines and the populations of patients at risk from disease who are underserved or ill-considered in these new strategies. It should be noted that EASD, ECS, and IAS also have just published new guidelines positions contrary to the ACC/AHA Lipids and prevent CVD guidelines. We are currently thoroughly reviewing all four guidelines and a position statement on the Hypertension and Lifestyle guidelines, and our comments will be released in the near future.

In the past, AACE has generally agreed with the ATP 3 NCEP guidelines for cholesterol and lipid management and its update in 2004. No update by the NCEP has been forthcoming since that date. These new guidelines from AHA/ACC focus exclusively on large scale randomized clinical trials. They are highly restrictive regarding the database considered for this new analysis and omit much new information. Furthermore, no research after 2011 has been considered. Taken together, these actions have resulted in a considerable number of underserved, at-risk patients being omitted from consideration.

A new CHD risk calculator has been introduced into these new guidelines as a replacement for the older Framingham risk calculator. This new calculator is outdated, and no longer models the totality of the U.S. population; it therefore has only limited applicability. This new calculator is based upon similarly outmoded data and, as well, is not validated. Additionally, the focus of the new guidelines is initiation of statin therapy and not the level of LDL cholesterol attained. To the extent that full dose statins are recommended, we agree with this position. But, AACE disagrees with the notion of removing LDL goals and that statin therapy alone is sufficient for all at-risk patients. A considerable number of high-risk patients with multiple risk factors, diabetes, and established coronary disease do not attain adequate LDL cholesterol and other lipid abnormalities reductions without further therapies in addition to statins or without the use of highly effective statins. Non statin agents may be needed in combination with statins in very high risk groups to produce adequate LDL-cholesterol reduction to levels proven to further reduce CHD risk. Failure to set targets for treatment makes the degree of risk reduction produced in these groups unknowable and eliminates proper monitoring of management. Worse, It diverts attention away from the ongoing disease process and may lead to unjustified complacency regarding disease recurrence and its prevention.

The Obesity Guidelines are similarly limited in their scope. They do not include data past 2011. These new guidelines fail to classify obesity as a disease and continue the paradigm of BMI-centric risk stratification, both of which are contrary to recently stated AACE positions. Moreover, the guidelines do not include any consideration of pharmacology to assist with weight loss, despite the availability of at least 2 new oral agents, approved by the FDA for obesity management, which produce significant weight reduction. The sole focus of these new guidelines is on lifestyle intervention and bariatric surgery. This is insufficient to meet the needs of the entire population of patients with overweight or obesity related complications and is therefore inadequate as well.

AACE welcomes the intent of the AHA and ACC in the creation of these new guidelines but does not agree with the complete content and therefore cannot endorse them.

We recommend that AACE members continue to refer to AACE guidelines and position statements on Lipids and Obesity to assist decision making in their practices.

To access AACE guidelines, please visit https://www.aace.com/publications/guidelines.

To access the AACE Lipids guidelines directly, visit https://www.aace.com/files/lipid-guidelines.pdf.

To access AACE position statements and AACE consensus statements, visit https://www.aace.com/publications/position-statements.

Sincerely,

Jeffrey I. Mechanick, MD, FACP, FACE, FACN, ECNU
President, AACE

Yehuda Handelsman, MD, FACP, FACE, FNLA
Chair, Lipids and Diabetes Scientific Committees

W. Timothy Garvey, MD
Chair, Obesity Scientific Committee