Implications of the 2013 ACC/AHA Cholesterol Guidelines for Adults in Contemporary Cardiovascular Practice: Insights From the NCDR PINNACLE Registry

Study Questions:

What is the impact of the 2013 American College of Cardiology (ACC)/American Heart Association (AHA) cholesterol guidelines on current US cardiovascular practice?


Data collected between 2008 and 2013, from the National Cardiovascular Data Registry (NCDR) Practice Innovation and Clinical Excellence (PINNACLE) Registry, were used for the present analysis. Cardiology practices voluntarily participate in the PINNACLE Registry as part of a national office-based cardiovascular quality improvement program. The PINNACLE Registry included data on 1,711,326 patients treated in 111 US cardiovascular practice clinics from 2008 to 2012. Patients were excluded from the present study if they did not fit one of the risk groups or had missing data on low-density lipoprotein cholesterol (LDL-C), race, smoking, or other variables. Lipid-lowering therapies and LDL-C testing patterns by risk group defined in the 2013 guidelines (atherosclerotic cardiovascular disease [ASCVD], diabetes, LDL-C ≥190 mg/dl, or an estimated 10-year ASCVD risk ≥7.5%) were examined.


A total of 1,174,545 patients were included in this analysis, of which 1,129,205 (96.1%) were statin-eligible (91.2% ASCVD, 6.6% diabetes, 0.3% off-treatment LDL-C ≥190 mg/dl, 1.9% estimated 10-year ASCVD risk ≥7.5%). More men than women qualified for the ASCVD or estimated 10-year ASCVD risk ≥7.5% risk groups, while more women than men qualified for the diabetes, LDL-C ≥190 mg/dl, or no risk criteria risk groups. Among the ASCVD risk group, 25.3% had diabetes. The median estimated 10-year ASCVD event risk was 20.6% for the ASCVD group, 16.2% for the diabetes group, 12.5% for the LDL group, 13.8% for the estimated risk ≥7.5% group, and 15.6% for the no risk criteria group (the median score is 15.6% because, in line with guideline recommendations, patients over 75 years of age are not included in the estimated risk ≥7.5% group). A total of 377,311 (32.4%) patients were not receiving statin therapy and 259,143 (22.6%) were receiving nonstatin therapies. During the study period, 20.8% of patients had two or more LDL-C assessments, and 7.0% had more than four.


The authors concluded that currently in the United States, 32.4% of statin-eligible patients, as defined by the 2013 ACC/AHA cholesterol guidelines, were not currently receiving statins. A significant number of patients (22.6%) were receiving nonstatin lipid-lowering therapies.


These data, along with an excellent editorial by Dr. Nanette Wenger, highlight the heterogeneity of current practice patterns related to lipid-lowering therapies. Use of registry data can assist in understanding how practice differs from guidelines, in addition to adding to our understanding of benefits and costs of recommendations, which impact large numbers of Americans.

Keywords: AHA Annual Scientific Sessions

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