New Risk Assessment and Cholesterol Guidelines Spark Debate

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"In the debate about the risk assessment tool released last week... important issues have been overlooked," write ACC President John Gordon Harold, MD, MACC, and American Heart Association President Mariell Jessup, MD, FAHA, in a New York Times letter-to-the editor. "It would be a shame if overstated criticism of the risk assessment tool prevented physicians and patients from having important conversations about their risks and actions that they can take to reduce risks." (Read the letter.)

The letter is in response to a recent NYT article and a commentary published in The Lancet. The Lancet piece suggests that while recent ACC/AHA cholesterol guidelines take several major steps forward that will simplify and improve care for higher risk patients, including those with diabetes, "it is in the realm of primary prevention that the new guidelines are likely to be more controversial.”

According to the commentary authors, the ACC/ AHA guidelines use a newly developed risk prediction algorithm that could result in many primary prevention patients taking statin therapy where there is little trial evidence, while potentially denying statin therapy to other patients despite trial evidence of efficacy. "In primary prevention, instead of predicting risk and presuming benefit, an alternative and simpler policy of asking 'what works?' and 'in whom?' based on trial evidence would reduce this problem and result in evidence-based public health recommendations for statin therapy in patient groups for whom we have hard data showing efficacy," the authors note.

Both the ACC and AHA vigorously defend the recently published risk assessment and cholesterol guidelines despite the recent media reports. "The risk assessment tool, while not perfect, is a significant improvement over the previous recommendations for preventing heart attacks that were based almost solely on levels of LDL cholesterol," the NYT letter states.

In a separate ACC/AHA joint statement, Harold notes that "clinical practice guidelines such as these should not take the place of sound clinical judgment. These guidelines should enable a discussion between a patient and their health care provider about the best way to prevent a heart attack or stroke, based on the patient’s personal health profile and their preferences. The risk calculator score is part of that discussion, because it provides specific information to the patient about their personal health. A high score does not automatically mean a patient should be taking a statin drug."

Keywords: Cholesterol, Stroke, Public Health, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Risk Assessment, Diabetes Mellitus, Primary Prevention

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