ACC/AHA Superior to ESC/EAS Guidelines for Prevention With Statins in Non-Diabetic Europeans

Study Questions:

Both lipid-based and risk prediction models are used in the current American College of Cardiology/American Heart Association (ACC/AHA) and European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines for statin use in primary prevention. Risk prediction matches the intensity of treatment with the absolute risk of atherosclerotic cardiovascular disease (ASCVD) risk of the individual. The US model uses the Pooled Cohort Equation (US-PCE) to predict any ASCVD and the European model uses the Systematic COronary Risk Evaluation (European-SCORE) to predict fatal ASCVD. What is the relative value in utilizing the European Copenhagen General Population Study?


The study was performed using the 44,889 persons aged 40–75 years (57% women) recruited in 2003-2009 in Copenhagen, all free of ASCVD, diabetes, and statin use at baseline. There were a total of 2,217 ASCVD events (nonfatal myocardial infarction [MI], coronary death, and stroke) and 199 fatal ASCVD events through 2014.


Mean age was 56 years, systolic blood pressure was 138 mm Hg, low-density lipoprotein cholesterol was 125 mg/dl, high-density lipoprotein cholesterol was 60 mg/dl, and 22% were smokers. US-PCE 10-year any ASCVD risk was 5.3% and European SCORE 10-year fatal ASCVD was 1.6%. There were 10 and 14 times more any ASCVD events using US-PCE than fatal ASCVD events with the European-SCORE in men and women. The predicted-to-observed event ratio was 1.2 using US-PCE for any ASCVD and 5.0 using European-SCORE for fatal ASCVD. The US-PCE, but not the European-SCORE, was well-calibrated around decision thresholds for statin therapy. For a Class I (high risk) recommendation, 42% of individuals qualified for statins using the US guidelines versus 6% with the European guidelines. Using US versus European-defined statin eligibility led to a substantial gain in sensitivity (+62% for any ASCVD and +76% for fatal ASCVD) with a smaller loss in specificity (-35% for any ASCVD and -36% for fatal ASCVD). Similar differences between the US and European guidelines were found for men and women separately, and for intermediate risk (ClassIIa) recommendations. The sensitivity and specificity of a US-PCE risk of 5% were similar to those of a European-SCORE risk of 1.4%, whereas a US-PCE risk of 7.5% was similar to a European-SCORE risk of 2.4%.


The US ACC/AHA guidelines were superior to the European ESC/EAS guidelines for primary prevention of ASCVD, that is, for accurately assigning statin therapy to those who would benefit.


The US guidelines for statin use are more liberal and the US-PCE risk predictor has been ‘accused’ of overestimating because the model used relatively old population data sets. That was not the case in this contemporary European cohort of whites.

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

Keywords: Atherosclerosis, Blood Pressure, Cholesterol, HDL, Cholesterol, LDL, Diabetes Mellitus, Dyslipidemias, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Lipoproteins, HDL, Myocardial Infarction, Primary Prevention, Risk Assessment, Stroke

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