Am Fam Physician. 2014;90(4):online
Related Practice Guidelines: ACC/AHA Release Updated Guidelines on the Treatment of Blood Cholesterol to Reduce ASCVD Risk
Related Editorial: Should Family Physicians Follow the New ACC/AHA Cholesterol Treatment Guideline? Yes: Implementing the New ACC/AHA Cholesterol Guideline Will Improve Cardiovascular Outcomes
Related Editorial: Should Family Physicians Follow the New ACC/AHA Cholesterol Treatment Guideline? Not Completely: Why It Is Right to Drop LDL-C Targets, but Wrong to Recommend Statins at a 7.5% 10-Year Risk
Clinical Question
How many more adults will be eligible for statin therapy under the 2013 American College of Cardiology (ACC)/American Heart Association (AHA) guideline than under previous guidelines?
Bottom Line
The new guideline from the ACC/AHA increases the number of adults between 40 and 75 years of age who are eligible to take statins by 12.8 million. The largest increases were among adults who would take statins for primary prevention and for adults between 60 and 75 years of age. The authors estimate that the switch could prevent 475,000 future cardiovascular events in this population. (Level of Evidence = 2c)
Synopsis
The 2004 guidelines from the Third Adult Treatment Panel (ATP III) of the National Cholesterol Education Program recommended statin therapy on the basis of the presence of specific risk factors, such as diabetes mellitus or cardiovascular disease (CVD), and on specified treatment targets according to risk level. The 2013 ACC/AHA guideline suggests statins for all adults at risk of CVD, regardless of low-density lipoprotein cholesterol (LDL-C) levels. The research team used National Health and Nutrition Examination Survey (NHANES) data from 2005 to 2010 to determine the proportion of adults who would be eligible to take statins under each guideline and then extrapolated those results to the U.S. population at large. They also compared the risk profiles of patients eligible for statins under each approach and the two different calculators used to estimate risk with each guideline. For the analysis, they used fasting blood samples of a subset of 3,773 adults between 40 and 75 years of age.
Of the study sample, 1,583 patients (42.0%) would receive a statin under the ATP III guidelines, whereas 2,135 (56.6%) would receive a statin under the 2013 ACC/AHA guideline, for an increase of 599 newly eligible adults (15.9%; higher than the net difference because some participants eligible under the ATP III guidelines would not be eligible under the new guideline). When these results were extrapolated to 115 million U.S. adults between 40 and 75 years of age, 43.2 million patients (37.5%) would be prescribed statins under the ATP III guidelines and 56.0 million patients (48.6%) were eligible under the new ACC/AHA guideline, representing an increase of 12.8 million adults. Of the newly eligible U.S. adults, 61.7% are men, the median age is 63.4 years, and the median LDL-C level is 105.2 mg per dL (2.72 mmol per L). The greatest difference in cholesterol recommendations is among adults 60 to 75 years of age (47.8% eligible under ATP III vs. 77.3% under ACC/ AHA). This study may be limited by the accuracy and representativeness of the NHANES data, including self-reporting of statin use and lack of data on peripheral vascular disease or transient ischemic attacks, which may underestimate rates of CVD in the sample.
Study design: Cross-sectional
Funding source: Foundation
Setting: Population-based
Reference: PencinaMJNavar-BogganAMD'AgostinoRBSr.et alApplication of new cholesterol guidelines to a population-based sample. N Engl J Med.2014; 370( 15): 1422– 1431.
