How is high cholesterol treated if I am Hispanic or Latino?

According to the 2018 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline on the Management of Blood Cholesterol, healthy lifestyle practices and statins are the cornerstone of treatment for adults with atherosclerotic cardiovascular disease (ASCVD) or high cholesterol (low density lipoprotein cholesterol [LDL-C] ≥190 mg/dL), including Hispanics/Latinos.¹ 

Cardiovascular disease is one of the leading causes of death among Hispanics/Latinos who live in the US.² However, in the US, Hispanic/Latino individuals differ from each other in culture, genetic ancestry, and environmental exposures, all factors that can influence cardiovascular risk.³

The ongoing Hispanic Community Health Study/Study of Latinos (HCHS/SOL) is a population-based cohort study (n= 16,415) that seeks to collect data on ASCVD risk factors in this diverse population.⁴  Their data suggest that hypercholesterolemia is the most prevalent risk factor among male US Hispanics/Latinos overall, and the second-most prevalent risk factor among female US Hispanics/Latinos after obesity. In the HCHS/SOL, 51.7% of men and 36.9% of women had either total cholesterol levels ≥240 mg/dL, high-density lipoprotein cholesterol <40 mg/dL, or LDL-C ≥160 mg/dL. Rates varied by country of origin, with highest rates among individuals of Central American origin. The data also demonstrated that the higher the degree of acculturation into US society (measured by years residing in the US and preferred language of English over Spanish) the higher the risk of adverse cardiovascular profiles. The existing data from the HCHS/SOL demonstrates wide variation among subgroups of Hispanic/Latino populations that should be considered when evaluating risk. The country of origin, socio-economic status, and degree of acculturation may influence diet and other lifestyle issues that can impact lipid levels and cardiovascular health.¹

The 2018 AHA/ACC Guidelines for the Management of Blood Cholesterol recommend a heart healthy diet that is consistent with ethnic and cultural preferences for individuals of Hispanic/Latino origin.¹ According to nutritional guidelines of the AHA and the ACC, a heart healthy lifestyle includes a diet that is rich in vegetables, fruits, whole grains, legumes, non-tropical vegetable oils, and healthy proteins.^5,6 These guidelines also recommend limiting the intake of sweets, sugar-sweetened beverages, and red meat. Caloric requirements should be determined by the need to avoid weight gain or to lose weight, if necessary, in order to minimize the risk for ASCVD. Physical exercise is also important to heart health and adults generally benefit from 40 minutes of aerobic physical activity 3 – 4 times per week.¹  

The amount statins can benefit an individual depends to some degree on how much the cholesterol levels decline in response to statins.⁷ A reduction of about 40 mg/dL in LDL-C causes a 20% to 25% drop in heart and blood vessel related events, such as myocardial infarction (MI), coronary deaths, strokes, and coronary revascularizations, for each year statins are taken. This is true even in people with lower levels of cholesterol to start with. The clinical trial data used to estimate the effectiveness of statins, however, was derived from disproportionately white populations.⁸ 

In general, Hispanics/Latinos respond well to statins, but not always to the same degree as other ethnicities.⁸ The reasons for the differences are not well understood. Blacks and Hispanics/Latinos have not been included in sufficient numbers in statin efficacy studies to determine the cause of the variation, but several factors may be involved.

Albert et al. compared data from 12,683 white and 5117 non-white moderately hypercholesterolemic participants in a randomized double-blind placebo-controlled study of rosuvastatin for the primary prevention of ASCVD.⁸ Statin use reduced ASCVD (MI, stroke, arterial revascularization, hospitalization for unstable angina, and cardiovascular death) by 45% for whites (hazard ratio [HR] 0.55, 95% confidence interval [CI] [0.43 – 0.69]) and only by 37% for nonwhites (HR 0.63, 95% CI [0.41 – 0.99]). Risk reduction among nonwhite Hispanics and blacks were similar, but they were grouped together for analysis because the relative sample sizes of blacks and Hispanics were too small to use for reliable comparison (confidence intervals crossed one). In this study it was not clear if this difference between racial groups was a result of differences in drug adherence, genetic differences in pharmacologic response to statins, or other factors.

Lipid-lowering medication, particularly statins, is recommended for individuals whose LDL-C is 190 mg/dL or higher, including Hispanics/Latinos.¹ The 2018 AHA/ACC guideline also recommends statins for people with LDL-C <190 mg/dL based on an assessment of their risk for future ASCVD events,¹ however this can be challenging to apply to US Hispanics because they were not included in the 2013 AHA/ACC ASCVD derivation cohort.⁹ The estimated 10-year risk of ASCVD events is generally lower among US Hispanics when compared to non-Hispanic whites.² For instance, DeFilippis et al. evaluated the accuracy of ASCVD risk predictors in the Multi-Ethnic Study of Atherosclerosis and found that 97 ASCVD events were predicted compared to 58 observed in Hispanic men, and 60 ASCVD events were predicted compared to 33 observed in Hispanic women.¹⁰ Similar over-estimation of risk was found in a large clinical population followed for five years (n=307,591 adults, of which 18,745 were Hispanic).¹¹

Because the available risk calculators have not been thoroughly studied with respect to their accuracy in Hispanics/Latinos, the 2018 Guidelines recommend that Hispanics/Latinos use the risk calculator called the Pooled Cohort Equation (PCE) for whites, unless there is African American ancestry, in which case they should use the PCE for blacks.¹ 

^References

1. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol. J Am Coll Cardiol 2018.
2. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics--2016 update: a report from the American Heart Association. Circulation 2016; 133 (4): e38-e360.
3. Conomos MP, Laurie CA, Stilp AM, et al. Genetic diversity and association studies in US Hispanic/Latino populations: applications in the Hispanic Community Health Study/Study of Latinos. Am J Hum Genet 2016; 98 (1): 165-184.
4. Daviglus ML, Pirzada A, Talavera GA. Cardiovascular disease risk factors in the Hispanic/Latino Population: lessons from the Hispanic Community Health Study/Study of Latinos. Prog Cardiovasc Dis 2014; 57 (3): 230-236.
5. Eckel R, Jakicic J, Ard, JD et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk. J Am Coll Cardiol 2014; 63 (25).
6. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC /TOS guideline for the management of overweight and obesity in adults. J Am Coll Cardiol 2014; 63 (25): 2985-3023.
7. Collins R, Reith C, Emberson J, et al. Interpretation of the evidence for the efficacy and safety of statin therapy. Lancet 2016; 388 (10059): 2532-2561.
8. Albert MA, Glynn RJ, Fonseca FAH, et al. Race , ethnicity , and the efficacy of rosuvastatin in primary prevention: The Justification for the Use of Statins in Prevention: An Intervention Trial Evaluating Rosuvastatin (JUPITER) trial. Am Heart J 2019; 162 (1): 106-114.e2.
9. Goff DCJ, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63 (25 Pt B): 2935-2959.
10. DeFilippis AP, Young R, McEvoy JW, et al. Risk score overestimation: the impact of individual cardiovascular risk factors and preventive therapies on the performance of the American Heart Association-American College of Cardiology-Atherosclerotic Cardiovascular Disease risk score in a modern multi-ethnic cohort. Eur Heart J 2017; 38 (8): 598-608.
11. Rana JS, Tabada GH, Solomon MD, et al. Accuracy of the atherosclerotic cardiovascular risk equation in a large contemporary, multiethnic population. J Am Coll Cardiol 2016; 67 (18).