Monday, December 23, 2013 9:30 am EST




The following message was sent to members of the American Association of Clinical Endocrinologists (AACE) in response to recent guidelines published the American Heart Association (AHA) and the American College of Cardiology (ACC):

 Dear Members,

The American Heart Association (AHA) and the American College of Cardiology (ACC) have issued four new guidelines: The Management of Cholesterol, Lifestyle Management to Reduce CV Risk, and, along with The Obesity Society (TOS), guidelines on the Management of Obesity.  The AHA, ACC, and the Centers for Disease Control and Prevention (CDC) issued a science advisory on the management of 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 European Association for the Study of Diabetes (EASD), the European Society of Cardiology (ESC), and the International Atherosclerosis Society (IAS) also have recently published new guidelines and positions which are somewhat contrary to the AHA/ACC lipids guidelines. Therefore, the new AHA/ACC guidelines are now among many available guidelines, including the AACE Lipids Guidelines, to which clinicians can refer. We are currently thoroughly reviewing all four of the AHA/ACC guidelines and the science advisory on the management of hypertension, and our comments will be released in the near future.

In the past, AACE has generally agreed with the Adult Treatment Panel 3 (ATP3) National Cholesterol Education Panel (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 and omit much new information. Furthermore, no research after 2011 has been considered. Taken together, these actions have resulted in a considerable number of at-risk patients being omitted from consideration.

A new Coronary Heart Disease (CHD) risk calculator has been introduced as one of these new guidelines. This new calculator is already outdated.  It is based upon outmoded data, does not model the totality of the U.S. population, has not been validated, and therefore has only limited applicability. Additionally, the focus of the new Lipid 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 reductions in LDL cholesterol and other lipid abnormalities without further therapies in addition to statins.

Non-statin agents may be needed in combination with statins in very high risk groups to produce adequate LDL-cholesterol reduction 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 new 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 of the new FDA-approved pharmacologic agents to assist with weight loss.  As a result, the focus of these new guidelines is primarily 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.

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. 

Note: Minor clarifications have been made to this document to update the AACE Member Alert originally distributed on November 21, 2013.