The ACC/AHA 2013 Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Disease Risk in Adults: The Good, the Bad, and the Uncertain: A Comparison With ESC/EAS Guidelines for the Management of Dyslipidaemias 2011

Perspective:

The following are 10 points to remember from a perspective that compares and contrasts the 2013 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines on the control of blood cholesterol to reduce atherosclerotic cardiovascular disease (ASCVD) risk in adults with those from the European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS):

1. The ACC/AHA guidelines are based on a review of randomized clinical trials exclusively. The ESC/EAS guidelines consider all available evidence, including that from observational epidemiologic studies. The authors of the opinion caution that limiting the scope to randomized trials only may be a “statin-centric approach.”

2. There is consensus that low-density lipoprotein cholesterol (LDL-C) is a causal factor for ASCVD, and both guidelines emphasize a comprehensive management strategy that includes continued emphasis on lifestyle and risk factor modifications.

3. The definition of ASCVD varies slightly between guidelines. The ACC/AHA defines ASCVD as acute coronary syndromes, previous myocardial infarction, stable angina, prior coronary or other revascularization, ischemic stroke or transient ischemic attack, and atherosclerotic peripheral arterial disease. The ESC/EAS also includes any preclinical evidence of ASCVD on the basis of any imaging modality.

4. The 2013 ACC/AHA primary prevention threshold for treatment is 7.5% of a CV event over 10 years. The authors of the editorial opine that this will result in a greater number of patients being prescribed statin therapy.

5. The lowered primary prevention threshold for treatment may be beneficial in younger patients (with a low short-term risk but high lifetime risk), but would result in a very large number of older patients being offered therapy.

6. The new ACC/AHA guidelines do not recommend for (or against) the use of specific LDL-C or non-high-density lipoprotein (HDL)-C targets, but do suggest specific moderate- or high-intensity regimens. The authors of the editorial believe this may ‘confuse many physicians and miss the opportunity for enhancing medication adherence and patient engagement.’

7. The 2011 ESC/EAS guidelines classify the intensity of risk and specify LDL-C targets for each level of absolute risk.

8. The ACC/AHA guidelines advocate the use of the mixed pooled cohort equation to estimate CVD risk. The Systemic COronary Risk Evaluation (SCORE) algorithm performs well in Europe. The authors of the editorial caution that the pooled cohort risk equations may overestimate risk and require ‘much greater scrutiny before use.’ The ACC/AHA 10-year threshold of 7.5% corresponds to a 2.5% risk for CVD death over 10 years in the SCORE model (moderate risk).

9. The 2011 ESC/EAS guidelines may have a broader scope that offers guidance on all lipids (including elevated triglycerides) and the utility of other lipid fractions (e.g., triglyceride-rich lipoproteins, non-HDL-C, or apolipoprotein B) in risk assessment.

10. The authors of the editorial suggest that the ACC/AHA guidelines are ‘ambiguous’ about the role of additional lipid-lowering therapies with residual absolute risk despite prescription of high-intensity statin therapy.

Clinical Topics: Acute Coronary Syndromes, Diabetes and Cardiometabolic Disease, Dyslipidemia, Prevention, Stable Ischemic Heart Disease, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Hypertriglyceridemia, Lipid Metabolism, Nonstatins, Novel Agents, Statins, Chronic Angina

Keywords: Myocardial Infarction, Acute Coronary Syndrome, Atherosclerosis, Ischemic Attack, Transient, Angina, Stable, Hypertriglyceridemia, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Lipoproteins, Peripheral Arterial Disease, Risk Factors, Europe, Peripheral Vascular Diseases, Primary Prevention, Metabolic Syndrome X, Cholesterol, Dyslipidemias, Epidemiologic Studies, Triglycerides, Risk Assessment, United States


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