Cholesterol screening guidelines consensus, evidence, and the departure from common sense.

Abstract

In this issue of Circulation , Garber and Browner1 present a defense of the American College of Physicians (ACP) guidelines for cholesterol screening, which were originally published in Annals of Internal Medicine in May 1996.2 The bases of these guidelines are that widespread cholesterol screening, such as that recommended by the National Cholesterol Education Program (NCEP),3 will result in the inappropriate use of cholesterol-lowering drugs in persons at low risk of developing coronary disease. The authors contend that the “evidence-based approach,” which the ACP allegedly used to reach these conclusions, is fundamentally different from the “consensus-based approach” used by the NCEP. Surprisingly, they then conclude that the NCEP “used logic similar to the ACP in development of its treatment recommendations.” Garber and Browner point out correctly that the two groups are drawing conclusions on the basis of the same database. The authors then discuss the process of developing such guidelines by citing the “extensive internal and external reviews” that the ACP guidelines underwent, without describing the content of those reviews or the background of the individuals asked to make them. This is, of course, in contrast to the NCEP process, which has been and continues to be a completely public endeavor. Contrary to what is implied by Garber and Browner, the NCEP process has been highly inclusive, drawing not only on individuals with expertise in lipids and lipoproteins but also on including individuals from other specialties and from the practicing community and even the most vociferous critics of cholesterol intervention. It is also important to recognize, as Garber and Browner state, that there is no disagreement that cholesterol lowering in individuals with clinically apparent vascular disease prevents recurrent events and saves lives. It is an important intervention central to the medical management of such patients; no debate …