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July 22, 2015
Newer Cholesterol Guidelines More Accurate in Identifying Patients at Risk
Boston—The 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines for the management of blood cholesterol recommended a seismic shift in the treatment approach for the primary prevention of cardiovascular disease (CVD). The focus moved from traditional risk factors, such as the management of low-density lipoprotein cholesterol levels, to absolute risk as estimated by the 10-year atherosclerotic CVD (ASCVD) score for statin treatment. Since then, the question has been whether the approach actually improves identification of adults at higher risk of cardiovascular events so they can get appropriate treatment. A new study, published recently in the Journal of the American Medical Association, finds that the new guidelines are more accurate and efficient in identifying increased risk of CVD events and the presence of subclinical coronary artery disease, especially for those at intermediate risk. The study team, led by researchers from Massachusetts General Hospital and Harvard Medical School, both in Boston, compared the new guidelines with the earlier National Cholesterol Education Program’s Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATP III) guidelines. Participants, including some from the offspring and third-generation cohorts of the Framingham Heart Study, underwent multi-detector computed tomography for CAC between 2002 and 2005 and were followed up for a median of nine years for new CVD. “Using 10-year follow-up data from asymptomatic patients enrolled in the Framingham Heart Study, our paper demonstrates that these new guidelines—which represent a shift in the treatment approach for primary prevention of cardiovascular disease—indeed improve identification of adults at higher risk for future cardiovascular events who were not captured by previous guidelines,” explained corresponding author Udo Hoffmann, MD, MPH. “Extrapolating our results to the approximately 10 million U.S. adults who would be newly eligible for statin therapy under the new guidelines, we estimate that between 41,000 and 63,000 cardiovascular events—heart attacks, strokes or deaths from cardiovascular disease—would be prevented over a 10-year period.” Overall, more participants were eligible for statin treatment when applying the 2013 ACC/AHA guidelines compared with the 2004 ATP III guidelines (39% vs. 14%). Among those eligible for statin treatment by the ATP III guidelines, 7% were found to develop incident CVD compared with 2% among noneligible participants. Applying the ACC/AHA guidelines, however, among those eligible for statin treatment, 6% developed incident CVD compared with only 1% among those not eligible. “This finding is consistent across subgroups and particularly important in participants at intermediate CVD risk on the Framingham Risk Scores, the most challenging group in clinical practice for whom to decide to initiate statin therapy,” the authors write. While past reports had suggested the new guidelines could increase the number of statin-eligible adults by almost 13 million, raising concerns of unnecessary exposure to the risk of statin therapy, the current study didn’t find that the difference was that dramatic. Extrapolating their findings to the approximately 10 million U.S. adults who are newly eligible for statins, an estimated 41,000 to 63,000 incident CVD events would be prevented over a 10-year period by adopting the ACC/AHA guidelines, study authors point out.
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