Application of New Cholesterol Guidelines to a Population-Based Sample

Study Questions:

To what extent do the 2013 American College of Cardiology and the American Heart Association (ACC/AHA) guideline on the treatment of blood cholesterol expand the indications for statin therapy for the prevention of cardiovascular disease (CVD)?


Using data from the National Health and Nutrition Examination Surveys of 2005-2010, the authors estimated the number, and summarized the risk-factor profile, of persons for whom statin therapy would be recommended (i.e., eligible persons) under the new ACC/AHA guidelines, as compared with the guidelines of the Third Adult Treatment Panel (ATP III) of the National Cholesterol Education Program. The results were extrapolated to a population of 115.4 million US adults between the ages of 40 and 75 years.


As compared with the ATP III guidelines, the new guidelines would increase the number of US adults receiving or eligible for statin therapy from 43.2 million (37.5%) to 56.0 million (48.6%). Most of this increase in numbers (10.4 million of 12.8 million) would occur among adults without CVD. Among adults between the ages of 60 and 75 years without CVD who are not receiving statin therapy, the percentage who would be eligible for such therapy would increase from 30.4% to 87.4% among men, and from 21.2% to 53.6% among women. This effect would be driven largely by an increased number of adults who would be classified solely on the basis of their 10-year risk of a cardiovascular event (CVE). Those who would be newly eligible for statin therapy include more men than women and persons with a higher blood pressure, but a markedly lower level of low-density lipoprotein cholesterol (LDL-C). As compared with the ATP III guidelines, the new guidelines would recommend statin therapy for more adults who would be expected to have future CVEs (higher sensitivity), but would also include many adults who would not have future events (lower specificity).


The new ACC/AHA guidelines on the treatment of blood cholesterol would increase the number of adults who would be eligible for statin therapy by 12.8 million, with the increase seen mostly among older adults without cardiovascular disease.


The ACC/AHA guidelines for cholesterol management have been controversial in part because of the dramatic change in risk stratification for selection of persons for statins, and the substitution of a degree of intensity of dosing for LDL-C lowering, rather than treatment to a target. The most dramatic change is that the new threshold for statins is a 7.5% or greater 10-year risk of a CVE. That includes the great majority of men ages 65 years and women 71 years and older. I have not seen data estimating the number needed to treat to reduce a CVE in the 60- to 75-year-olds, and the cost implications of seeing the patients in follow-up; in particular, the low-risk group of whom 10-15% will have side effects from statins.

Clinical Topics: Diabetes and Cardiometabolic Disease, Dyslipidemia, Lipid Metabolism, Nonstatins, Novel Agents, Statins

Keywords: Cholesterol, Dyslipidemias, Follow-Up Studies, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Cardiovascular Diseases, Risk Factors, Blood Pressure, Nutrition Surveys

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