Cholesterol Guideline Differences in Europe and the US

Study Questions:

What is the relative effect of the American College of Cardiology/American Heart Association (ACC/AHA) and European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) cholesterol guidelines when applied to a population-based sample?


The authors used nationally representative data for 3,055 adults aged 40-65 years from the 2007-2012 National Health and Nutrition Examination Surveys (NHANES) for the United States and for 1,060 adults aged 40-65 years from the 2011 survey for Poland. The number and characteristics of adults recommended for statin therapy according to the ACC/AHA and ESC/EAS guidelines were evaluated, and characteristics were compared between adults with discordant recommendations.


The 3,136 US adults aged 40-65 years population estimates translate to 97.9 million adults. Similarly, the 1,060 Polish adults in NATPOL (2,011) aged 40-65 years represent 13.5 million adults. The US cohort had a greater prevalence of cardiovascular disease (CVD) (i.e., stroke, myocardial infarction), obesity, and diabetes, but less smoking and more taking statins. Using weighted data, in the United States, 43.8% of adults would be recommended for statin therapy according to ACC/AHA guidelines, and 39.1% according to ESC/EAS guidelines. In Poland, 49.9% of adults would be recommended for statin therapy under ACC/AHA guidelines compared with 47.6% under ESC/EAS guidelines. Among individuals without CVD and not currently taking statins, 11.0% of US and 10.5% of Polish adults had discordant guideline recommendations. Compared with individuals recommended for statin therapy by the ESC/EAS guidelines but not the ACC/AHA guidelines, those recommended for statin therapy under the ACC/AHA guidelines only had less chronic kidney disease; however, these individuals were also more likely to smoke, have lower high-density lipoprotein cholesterol (HDL-C) levels, and have higher predicted 10-year risk of CVD.


Despite differences in the ACC/AHA and EAS/ESC guidelines, the numbers of adults aged 40-65 years recommended for cholesterol-lowering therapy under each guideline were similar when applied to nationwide representative samples from both the United States and Poland. Discordant recommendations were driven by differences in the risk equations used in the two guidelines and different recommendations for adults with chronic kidney disease.


The findings are interesting in that the guidelines vary considerably, with the ACC/AHA leading to much higher statin use in ‘primary prevention.’ While the actual benefit from each guideline is unknown, in the final analysis, the societal statin costs are similar. Data for cost/benefit should be available via national health care databases in many countries or health maintenance organizations in the United States.

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

Keywords: Cardiovascular Diseases, Cholesterol, Diabetes Mellitus, Dyslipidemias, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Kidney Diseases, Lipoproteins, HDL, Myocardial Infarction, Obesity, Practice Guidelines as Topic, Primary Prevention, Renal Insufficiency, Chronic, Smoking, Stroke

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