What impact will current trial data have on future guideline recommendations?

Abstract

The current Third Joint European Societies' Guidelines on Cardiovascular Disease Prevention in Clinical Practice reflect an active approach to cardiovascular disease (CVD) prevention. These guidelines have shifted the emphasis from coronary heart disease to total atherosclerotic CVD. A new risk prediction system, Systematic Coronary Risk Evaluation (SCORE), has been developed to define risk in terms of absolute 10-year risk of a fatal cardiovascular event. The definition of high risk has also been refined. The currently recommended goals for total and low-density lipoprotein (LDL) cholesterol are based on the evidence pool that was available at the time of publication. More recent evidence from the Heart Protection Study (HPS), the lipid-lowering arm of the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT-LLA), and the Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis in Myocardial Infarction 22 (PROVE IT-TIMI 22) trial indicates that lowering LDL cholesterol levels beyond the currently recommended goals can produce incremental reductions in cardiovascular morbidity and mortality. Results from the recently completed Treating to New Targets (TNT) study lend further support to implementing lower lipid goals than those currently suggested by guidelines. Results from the ongoing Incremental Decrease in Endpoints through Aggressive Lipid Lowering (IDEAL) trial may provide additional evidence in support of the implementation of lower lipid goals. Nevertheless, the scope of future guidelines extends well beyond lipid targets. Guidelines of the future are likely to provide increasingly comprehensive recommendations on combined risk reduction, to publicize the characteristics of healthy people by highlighting acceptable levels of all cardiovascular risk factors, and to refine the concept of evidence-based medicine by shifting the focus from drug therapy to preventive therapy.