Birmingham, AL—A new guideline published 6 years ago that pushed for a risk-based approach to treating high cholesterol apparently had the desired effect.

A study in the Journal of the American College of Cardiology confirms that implementation of the 2013 American College of Cardiology/American Heart Association Guideline on the Treatment of Blood Cholesterol led to improved overall cholesterol levels for American adults. That was the case especially for those using cholesterol-lowering medications, according to the study led by University of Alabama at Birmingham researchers.

The ACC/AHA Cholesterol Guideline, which was released in 2013, called for a different approach to cholesterol management for people at high risk of cardiovascular diseases: It promoted a risk-based approach versus a targeted LDL-C approach. At the time, the guideline identified four major groups of patients for whom statins would have the greatest benefit in preventing strokes and heart attacks, while also emphasizing the importance of adopting a heart-healthy lifestyle.

Even though a new cholesterol guideline was published in 2018, the risk-based approach did not change.

For the study, researchers examined the long-term effects of the 2013 guidance for cholesterol management by tracking nationwide trends in total cholesterol, triglycerides, and LDL cholesterol, as well as high-cholesterol awareness and statin usage.

The study team used the CDCs National Health and Nutrition Examination Survey (NHANES) to assess trends in lipid levels between 2005 and 2006, which was before the guideline release; 2011–2014, during the guideline release period; and 2015–2016, after the guideline release.

Excluded in the study were people with an LDL cholesterol of greater than or equal to 190 mg/dL—since there were less than 50 people in each NHANES cycle—Americans younger than age 20 years and women who were pregnant or breastfeeding.

With 32,278 patients assessed, the study found significant cholesterol declines among Americans taking lipid-lowering medication. In fact, the researchers report that the age-adjusted total cholesterol declined from 206 mg/dL in 2005–2006 to 191 mg/dL in 2013–2014, with an additional drop to 187 mg/dL in 2015–2016.

At the same time, average LDL cholesterol among adults taking lipid-lowering medication decreased from 122 mg/dL in 2005–2006 to 107 mg/dL in 2013–2014 to 101 mg/dL in 2015–2016.

During the study period, patients informed they had high cholesterol increased from 63.6% in 2005–2006 to 69.4% in 2011–2012, although the percentage remained unchanged through 2015–2016. In addition, the proportion of adults eligible for statin use who were actually taking the drugs increased from 41.3% in 2005–2006 to 49.2% in 2015–2016.

American adults with diabetes had a higher percentage, increasing from 48.3% in 2005–2006 to 60.2% in 2015–2016.

As a group designated in the guideline for whom statins would have the most benefit, patients with a 10-year predicted ASCVD risk of greater than or equal to 7.5% held steady at approximately 30% with a modest decrease of 4% in 2015–2016. That decrease in statin use might be related to guideline recommendations calling for a risk-benefit discussion with shared decision-making when deciding on a statin prescription, the researchers suggest.

“From a public health perspective, the 2013 guidelines have seemingly improved overall cholesterol levels among American adults on statins,” explained senior author Pankaj Arora, MD, a physician-scientist in the Division of Cardiovascular Disease, University of Alabama at Birmingham. “The areas that are unchanged or have decreased since guideline implementation are awareness of high cholesterol and statin use within the highest risk groups. Targeting gaps in clinician guideline education and in patients’ perception on statin safety may improve guideline dissemination further.”

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