Since none of the other cholesterol-lowering-medicines, which were often added to statins to further lower cholesterol, have been shown to further improve cardiovascular outcomes, the guidelines no longer recommend combination therapies with such augmenting medications.

The major message emerging from the new guidelines is that lowering cholesterol does not necessarily lead to improved cardiovascular outcomes, such as reduced strokes and heart attacks. The reasons why statins improve cardiovascular outcomes have more to do with improving the inside health of arteries by other means, which have little to do with lowering cholesterol.

Hence, the new guidelines emphasize the statin-treatment-intensity rather than the after-treatment cholesterol levels. Treatment is either high intensity, which uses maximal doses of statins. Or it is medium intensity, which uses moderate doses of statins. Low intensity treatment, which uses small doses of statins, is no longer recommended.

A cardiovascular risk calculator is used to determine cardiovascular risk. The calculator, which can be accessed on the Internet by using the address: http://my.americanheart.org/cvriskcalculator uses nine factors -age, sex, race, total cholesterol, HDL (bad) cholesterol, systolic blood pressure, taking medicines for high blood pressure, diabetes, and smoking- to determine the ten-year risk of heart attacks and strokes. If the risk is 7.5% or more, the guidelines recommend treatment with statins, even if the cholesterol is not high.

Based on these guidelines, doctors are now supposed to screen all persons 21 years or older by measuring their LDL cholesterol, questioning them about cardiovascular risk factors, and calculating their ten-year cardiovascular risk by using the above formula. When this is properly done, five groups will emerge:

a) Those with no cardiovascular risks-such as high blood pressure, diabetes, smoking, obesity, and sedentary life style-and whose calculated ten-year risk is below 7.5% will need no treatment, but they do require surveillance.

b) Those with clinical cardiovascular diseases-such as completed strokes, reversible mini stokes, heart attacks, angina pectoris, arterial bypass surgeries or stents, and narrowed leg arteries that limit walking- should receive high-intensity statin therapy regardless of cholesterol levels, age, or risk calculation. However, patients with certain liver or kidney troubles, age >75, and intolerance to statins, should be given intermediate-intensity statin therapy instead.

c) Those with diabetes, age 40-75, and LDL cholesterol 70-189 mg/dl, if their calculated risk is 7.5% or more, should receive high-intensity statin therapy. If the risk is < 7.5%, moderate-intensity statin therapy is substituted.

d) Those who do not have diabetes, are 40-75 years old, have an LDL cholesterol of 70-189 mg/dl, and a calculated risk of 7.5% or more should receive moderate-intensity statin therapy. However, if their calculated risk is <7.5%, they will require no therapy.

e) Those with LDL cholesterol of 190 mg/dl or more should receive high-intensity statin therapy regardless of other factors.

The guidelines derive from controlled studies, which have shown that the benefits of statins outweigh their uncommon risks of muscle injury, liver injury, and new-onset diabetes. However, because of insufficient data, there are no guidelines for those >75 years old, if they have no clinical cardiovascular disease.

To conclude, the guidelines do not support the use of non-statin cholesterol lowering medications in statin-intolerant patients nor do they support giving them combined with statins to further lower cholesterol levels. Also, the guidelines no longer support re-evaluating cholesterol levels after treatment is given because cholesterol target-levels are no longer the goal. Moreover, the traditional use of coronary calcium scores and C-reactive protein as cardiovascular disease markers is no longer recommended. The guidelines will greatly increase the number of patients who will be treated with statins.

This major shift in cholesterol-treatment-strategy is being actively debated. Agreement is by no means unanimous and modifications are expected with the accumulation of new data. Nevertheless, evidence-based-science has issued its edict, which will affect a major change in how we understand, prevent, and treat atherosclerotic cardiovascular diseases.