Cholesterol Management Guidelines Research Articles

Increased statin eligibility based on ACC/AHA versus NCEP guidelines for high cholesterol management in Chile

In 2013, the American College of Cardiology and the American Heart Association (ACC/AHA) jointly released new guidelines for cardiovascular risk assessment and cholesterol management that substantially modified the previous recommendations proposed by the National Cholesterol Education Program (NCEP) in 2001. The relative impact of these new guidelines on potential statin use has not been estimated in Latin American populations. To estimate and compare eligibility for statin therapy based on ACC/AHA and NCEP guidelines in adult Chilean population. Using data from the last National Health Survey (2009-2010 NHS), we conducted a cross-sectional analysis in a ​representative sample of the Chilean adult population and calculated the proportion of individuals that would receive statins under each set of guidelines. According to ACC/AHA guidelines, the population eligible for statin treatment increased from 21.7% (NCEP guidelines) to 33.2% (overall 53% increase). This effect was more pronounced among women (29.6% under ACC/AHA vs 15.6% under NCEP) and with those of advanced age (75% of the subjects >60 years of age compared with 46% under NCEP). The newly eligible group included more women and older subjects and individuals with lower LDL cholesterol levels. Compared with NCEP recommendations, the new ACC/AHA guidelines significantly increased the number of Chilean adults eligible for statin therapy. Full implementation of the new recommendations may have important public health implications in Chile and other Latin American countries, as more women and older subjects without cardiovascular disease would qualify for statin treatment.

Abstract 17287: Increase in Utilization of High-intensity Statin Among New Users After the Release of the 2013 ACC/AHA Cholesterol Management Guideline

Introduction: To characterize changes in statin utilization patterns after the release of the 2013 ACC/AHA cholesterol management guideline. Methods: Using administrative claims and laboratory results data from the HealthCore Integrated Research Database, statin use was captured during the 4 quarters before and after release of the 2013 ACC/AHA guideline. Individuals were classified into 4 statin benefit groups (SBG), as described in the ACC/AHA guideline. Patients new to statins were identified independently during each quarter. Results: An average of 205,358 patients were identified across the 4 SBG groups during each quarter, of whom an average of 3,658 were new statin users. New users were 41% women and 61 years old on average. Results are shown in Figure 1. In SBG 1, high-intensity statin use in patients <75 years increased from an average of 19.6% per quarter before the guideline to 24% in the quarters afterward. In SBG 2, there was a gradual increase in high-intensity statin use following introduction of the guideline. In SBG 3, high-intensity statin use for patients with 10-year atherosclerotic cardiovascular disease (ASCVD) risk ≥7.5% increased during the post-guideline period, but little change was seen for moderate-intensity statin use for patients with ASCVD risk <7.5%. In SBG 4, a small increase in moderate- to high-intensity statin use was observed. Conclusions: The 2013 ACC/AHA guideline appeared to have a modest effect in the utilization of high-intensity statins among new users in the period immediately following its release. The increase was most marked in the use of high-intensity statins in ASCVD patients and in patients treated by specialists. Follow-up in future years to assess the impact of the ACC/AHA guideline is warranted.

Implications of Coronary Artery Calcium Testing Among Statin Candidates According to American College of Cardiology/American Heart Association Cholesterol Management Guidelines: MESA (Multi-Ethnic Study of Atherosclerosis)

BackgroundThe American College of Cardiology (ACC)/American Heart Association (AHA) cholesterol management guidelines have significantly broadened the scope of candidates eligible for statin therapy. ObjectivesThis study evaluated the implications of the absence of coronary artery calcium (CAC) in reclassifying patients from a risk stratum in which statins are recommended to one in which they are not. MethodsMESA (Multi-Ethnic Study of Atherosclerosis) is a longitudinal study of 6,814 men and women 45 to 84 years of age without clinical atherosclerotic cardiovascular disease (ASCVD) risk at enrollment. We excluded 1,100 participants (16%) on lipid-lowering medication, 87 (1.3%) without low-density lipoprotein levels, 26 (0.4%) with missing risk factors for calculation of 10-year risk of ASCVD, 633 (9%) >75 years of age, and 209 (3%) with low-density lipoprotein <70 mg/dl from the analysis. ResultsThe study population consisted of 4,758 participants (age 59 ± 9 years; 47% males). A total of 247 (5.2%) ASCVD and 155 (3.3%) hard coronary heart disease events occurred over a median (interquartile range) follow-up of 10.3 (9.7 to 10.8) years. The new ACC/AHA guidelines recommended 2,377 (50%) MESA participants for moderate- to high-intensity statins; the majority (77%) was eligible because of a 10-year estimated ASCVD risk ≥7.5%. Of those recommended statins, 41% had CAC = 0 and had 5.2 ASCVD events/1,000 person-years. Among 589 participants (12%) considered for moderate-intensity statin, 338 (57%) had a CAC = 0, with an ASCVD event rate of 1.5 per 1,000 person-years. Of participants eligible (recommended or considered) for statins, 44% (1,316 of 2,966) had CAC = 0 at baseline and an observed 10-year ASCVD event rate of 4.2 per 1,000 person-years. ConclusionsSignificant ASCVD risk heterogeneity exists among those eligible for statins according to the new guidelines. The absence of CAC reclassifies approximately one-half of candidates as not eligible for statin therapy.

Guideline-Based Statin Eligibility, Coronary Artery Calcification, and Cardiovascular Events

ImportanceThe 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines for cholesterol management defined new eligibility criteria for statin therapy. However, it is unclear whether this approach improves identification of adults at higher risk of cardiovascular events.ObjectiveTo determine whether the ACC/AHA guidelines improve identification of individuals who develop incident cardiovascular disease (CVD) and/or have coronary artery calcification (CAC) compared with the National Cholesterol Education Program’s 2004 Updated Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATP III) guidelines.Design, Setting, and ParticipantsLongitudinal community-based cohort study, with participants for this investigation drawn from the offspring and third-generation cohorts of the Framingham Heart Study. Participants underwent multidetector computed tomography for CAC between 2002 and 2005 and were followed up for a median of 9.4 years for incident CVD.ExposuresStatin eligibility was determined based on Framingham risk factors and low-density lipoprotein thresholds for ATP III, whereas the pooled cohort calculator was used for ACC/AHA.Main Outcomes and MeasuresThe primary outcome was incident CVD (myocardial infarction, death due to coronary heart disease [CHD], or ischemic stroke). Secondary outcomes were CHD and CAC (as measured by the Agatston score).ResultsAmong 2435 statin-naive participants (mean age, 51.3 [SD, 8.6] years; 56% female), 39% (941/2435) were statin eligible by ACC/AHA compared with 14% (348/2435) by ATP III (P < .001). There were 74 incident CVD events (40 nonfatal myocardial infarctions, 31 nonfatal ischemic strokes, and 3 fatal CHD events). Participants who were statin eligible by ACC/AHA had increased hazard ratios for incident CVD compared with those eligible by ATP III: 6.8 (95% CI, 3.8-11.9) vs 3.1 (95% CI, 1.9-5.0), respectively (P<.001). Similar results were seen for CVD in participants with intermediate Framingham Risk Scores and for CHD. Participants who were newly statin eligible (n = 593 [24%]) had an incident CVD rate of 5.7%, yielding a number needed to treat of 39 to 58. Participants with CAC were more likely to be statin eligible by ACC/AHA than by ATP III: CAC score >0 (n = 1015): 63% vs 23%; CAC score >100 (n = 376): 80% vs 32%; and CAC score >300 (n = 186): 85% vs 34% (all P < .001). A CAC score of 0 identified a low-risk group among ACC/AHA statin-eligible participants (306/941 [33%]) with a CVD rate of 1.6%.Conclusions and RelevanceIn this community-based primary prevention cohort, the ACC/AHA guidelines for determining statin eligibility, compared with the ATP III, were associated with greater accuracy and efficiency in identifying increased risk of incident CVD and subclinical coronary artery disease, particularly in intermediate-risk participants.

Applicability and potential clinical effects of 2013 cholesterol guidelines on major cardiovascular events

The applicability to different race/ethnic groups and effects on cardiovascular disease (CVD) outcomes of the 2013 American College of Cardiology and American Heart Association (ACC/AHA) guidelines for cholesterol management remain to be determined. We estimated the proportion of Korean adults who would be affected by the 2013 cholesterol guidelines and to determine the related effects on cardiovascular events. Using data from the Korean National Health and Nutrition Examination Survey of 2008 to 2012 (n = 18,573), we compared the estimated number of statin candidates under the 2013 ACC/AHA and the Third Adult Treatment Panel (ATP-III) guidelines and extrapolated the results to 19.0 million Koreans between the ages of 40 and 75 years. Using an external cohort (n = 63,329) from the 2003 National Health Examination with 7 years of prospective follow-up, we determined the potential effects of recent recommendations changes on atherosclerotic CVD events (composite of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke). Compared with the ATP-III guidelines, the ACC/AHA guidelines would increase the number of statin candidates from 3.5 million (18.6%) to 6.7 million (35.1%). The increase of statin candidates would be larger among older adults (60-75 years; from 29.8% to 74.9%) as compared with younger adults (40-59 years; from 15.6% to 19.8%) and among men (from 25.7% to 45.4%) compared with women (from 14.6% to 26.8%). In the external cohort, compared with adults who were recommended by neither of the 2 guidelines, those who were recommended by both and those who were recommended by ACC/AHA but not ATP-III guidelines had significantly higher risks of atherosclerotic CVD events (hazard ratios [HRs] 3.65 [95% CI, 3.33-4.02] and 3.98 [95% CI 3.64-4.35], respectively). However, adults who were recommended by ATP-III but not ACC/AHA guidelines did not have an increased risk (HR 0.90, 95% CI 0.64-1.28). In the Korean population, the 2013 ACC/AHA cholesterol guidelines would substantially increase the number of adults who are potentially eligible for statin therapy and would recommend statin therapy for more adults at higher cardiovascular risk. However, the clinician-patient discussion of the potential benefits, possible harms, and other factors before the initiation of statin therapy must be considered.

Abstract 123: Yield of Lipid Screening for Primary Prevention in a Young Cohort of Non-diabetic Patients Using the 2013 ACC/AHA ASCVD Risk Calculator

Background/Aim: The 2013 ACC/AHA cholesterol management guidelines advise checking lipids in all adults aged &gt; 20 years and repeating it every 4-6 years to identify individuals at high risk for atherosclerotic cardiovascular disease (ASCVD) because they may benefit from treatment. Statins can be considered in young adults with elevated ten year risk (defined as &gt;5%) or LDL cholesterol &gt;190 mg/dl. We aimed to assess the yield of lipid screening in this population. Methods: We conducted a retrospective cross-sectional study of patients aged 30-49 years who had lipid screening at their first primary care visit at a large health system from 2003-2012. Patients with known ASCVD and diabetes were excluded. We calculated 10-yr ASCVD risk by extrapolating the 2013 ACC/AHA ASCVD risk calculator to this population. Patients were subdivided by age in 5 year intervals, gender and history of smoking and hypertension. We calculated the percentage of patients with risk &gt;5% and patients or LDL &gt;190 mg/dl in each subgroup. Results: A total of 47,495 patients were included. The total number in each subgroup and the percentage with 10-yr estimated ASCVD risk &gt;5% are shown in Table 1. Approximately half (49.2%, 23,388/47,495) the population had very low risk with only 18/ 23,388 (0.08%) non-smoking, non-hypertensive patients having an elevated risk. Only 1/15,618 (0.006%) non-smoking non-hypertensive females &lt;50 years had a high risk. Less than 0.5% of non-smoking non-hypertensive males &lt;45 years had a risk &gt;5%. From 1% to &gt;75% of population in other subgroups had an elevated risk depending on risk factors. Only 667/ 47,495 (1.4%) patients had LDL cholesterol &gt;190 mg/dl. Conclusion: Yield of lipid screening is very low in non-smokers, especially in normotensive females &lt;50 years and males &lt;45 years, which constitute one-half of the screened population. Also, only 1.4% of the entire population cohort &lt;50 years had elevated LDL&gt;190 mg/dl. Guidelines for lipid screening should be reassessed for healthy non-smoking normotensive adults under 50 years of age.

GUIDELINE-BASED STATIN ALLOCATION TO DISTINGUISH BOTH CARDIOVASCULAR EVENTS AND CORONARY ARTERY CALCIFICATION IN THE COMMUNITY: A COMPARISON OF THE 2004 NCEP ATP III AND 2013 ACC/AHA CHOLESTEROL TREATMENT GUIDELINE

The 2013 ACC/AHA guidelines for management of blood cholesterol (ACC/AHA) have substantially increased the number of asymptomatic adults who are eligible for primary preventive statin therapy. We sought to determine whether these new guidelines significantly improve the identification of individuals

APPLICATION AND VALIDATION OF NEW CHOLESTEROL GUIDELINES IN AN ASIAN POPULATION

The applicability and validity of the new American College of Cardiology and American Heart Association (ACC/AHA) guidelines for cholesterol management remain undetermined in Asians. Using data from the Korean National Health and Nutrition Examination Survey of 2008 to 2012 (n=18,573), we compared

Cholesterol management in geriatric patients: new guidelines.

Pharmacists play an important role in the management of primary care disease states such as hypercholesterolemia. The 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines provide the pharmacist with pertinent treatment recommendations relevant to day-to-day clinical practice and geriatric care. This article reviews these new evidencebased guidelines for cholesterol management in general and for the elderly specifically. The new guidelines have implications for older adults remaining on or starting statin therapy. With this review, and based on the new guidelines, pharmacists will be informed on how to provide hyperlipidemia recommendations for the older adult. Monitoring of therapy, as well as adverse effects, will be reviewed, including differences among various practice settings.

Abstract 13249: European and American Blood Cholesterol Guidelines Result in Similar Rates of Statin Recommendations when Applied to a Country with High Cardiovascular Disease Risk

Introduction: The American Heart Association and American College of Cardiology (AHA/ACC) recently released updated guidelines for management of blood cholesterol, which differ from current European Society of Cardiology and European Atherosclerosis Society (ESC/EAS) guidelines. How these differences affect the overall number of individuals recommended for statin therapy in a country with high cardiovascular disease (CVD) risk remains unclear. Hypothesis: Due to the lower threshold for statin recommendations for primary prevention based on 10-year CVD risk under the AHA/ACC guidelines, more adults overall would be recommended for statin therapy under American compared to European guidelines. Methods: Using 2011 data from a nationwide cross-sectional survey in Poland (NATPOL), we estimated the number and characteristics of adults aged 40-65 recommended for lipid lowering therapy under the ESC/EAS and AHA/ACC guidelines. The survey sample of 1060 adults represented 13.5 million adults in Poland aged 40-65. Results: Under ESC/EAS guidelines, 47.6% of adults (44.6-50.7%) aged 40-65 were recommended for immediate statin therapy, compared to 49.9% (46.9-52.9%) under AHA/ACC guidelines. Among adults free of cardiovascular disease (CVD), 10.5% had discordant recommendations between guidelines. Individuals recommended for statin therapy under ACC/AHA but not ESC/EAS guidelines had less chronic kidney disease, higher HDL cholesterol, higher 10-year (AHA/ACC calculator) risk, and higher 30-year (Framingham) risk than adults recommended under ESC/EAS but not under ACC/AHA guidelines. Ten-year CVD mortality risk estimated by the SCORE algorithm was similar between the two groups. Conclusions: In spite of differences between current European and American cholesterol guidelines, when applied to a nationwide representative sample from a country with high CVD risk, the number of adults aged 40-65 recommended for cholesterol lowering therapy under each guideline was nearly identical. Although more adults met criteria for primary prevention based on 10-year CVD risk under new American guidelines, the impact of this is offset by additional criteria for statin therapy in current European guidelines.

Abstract 15615: Eligibility for Lipid Lowering Therapy Based on AHA/ACC Risk Score, Coronary Artery Calcification, and CVD Events- National Implications for the Appropriate Use of Preventive Pharmacotherapy: Multi-Ethnic Study of Atherosclerosis (MESA)

Background: It is estimated that according to ACC-AHA guidelines for cholesterol management an additional 12.8 million adults including 10.4 million for primary prevention are considered for moderate-high intensity statin therapy. We sought to determine whether coronary artery calcium (CAC) testing might identify individuals who are expected to derive the most, and the least, benefit from the prescribed pharmacotherapy. Methods: MESA is a longitudinal, population-based study of 6,814 men and women aged 45-84 without clinical cardiovascular disease (CVD) at enrollment. The following participants were excluded from the analysis: 1100 (16%) on lipid lowering medication, 87 individuals (1.3%) with absent LDL levels, 26 (0.4%) with missing risk factors for calculation of 10-yr risk of ASCVD based on the new pooled-cohort equations as well as 634 (9.3%) aged &gt;75 years. Results: The final study population consisted of 4,967 individuals (59±9 years, 47% males). Overall 255 (5.1%) hard CVD events were noted in follow-up of median 10.3 years (IQR=9.7-10.8). Based on the new guidelines (figure), 2449 (49%) were considered candidates for moderate-high intensity statin therapy at baseline. Of these, 41% had CAC=0 and had 5.2 CVD events/1000 person-years and 29% had CAC&gt;100 and they had 15.2 events/1000 person-years. Among the 610 individuals who would be considered candidates for moderate intensity statin , 350 (57%) had a CAC=0 and an event rate of 1.5/1000 person year. CAC testing was similarly able to risk stratify individuals across increasing levels (quartiles) of ASCVD risk &gt;7.5% (figure). Conclusion: Within MESA, nearly half of patients considered for statin therapy based on the new guidelines had CAC=0, and experienced a very low event rate and subsequent high number needed to treat to prevent one event. Our study findings suggest that CAC further refines the estimate of CVD risk and may facilitate informed shared decision-making regarding statin treatment.

What the guidelines do not say: statin non-benefit groups.

The 2013 American College of Cardiology/American Heart Association guidelines for management of low-density lipoprotein cholesterol (LDL-C) to reduce atherosclerotic cardiovascular disease (ASCVD) risk identified four groups of adults (40-75 years of age) with significant evidence for benefit from statin therapy: presence of clinical ASCVD or diabetes, age ≥21 years and LDL-C >190 mg/dl, and 10-year risk of hard ASCVD events ≥7.5 % as determined by the new Cardiovascular Risk Calculator. However, clinicians are faced daily with at-risk patients who do not clearly match one of these statin-benefit groups. Understanding the limitations of available evidence and awareness of additional published guidelines for statin non-benefit groups will help practitioners make personalized decisions with patients and inform the clinician-patient discussion regarding potential risks and benefits of statin therapy.

Is high-intensity statin therapy associated with lower statin adherence compared with low- to moderate-intensity statin therapy? Implications of the 2013 American College of Cardiology/American Heart Association Cholesterol Management Guidelines.

The recent cholesterol guideline recommends high-intensity statins in cardiovascular disease (CVD) patients. High-intensity statins are associated with more frequent side effects. Therefore, it may be of concern that these recommendations might reduce statin adherence. High-intensity statins are associated with lower adherence compared with low- to moderate-intensity statins. In a national database of 972,532 CVD patients from the Veterans Health Administration, we identified patients receiving statins between October 1, 2010, and September 30, 2011. We assessed statin adherence by calculating proportion of days covered (PDC) and determined whether high-intensity statin therapy was independently associated with a lower PDC. Statins were prescribed in 629,005 (64.7%). Of those, 229,437 (36.5%) received high-intensity statins. Mean PDC (0.87 vs 0.86, P < 0.0001) and patients with PDC ≥ 0.80 (76.3% vs 74.2%, P < 0.0001) were slightly higher for those receiving low- to moderate-intensity compared with high-intensity statins. In adjusted analyses, high-intensity statin use was associated with a significant but modest PDC reduction compared with low- to moderate-intensity statin use, whether PDC was assessed as a continuous (β-coefficient: -0.008, P < 0.0001) or categorical (PDC ≥ 0.80 [odds ratio: 0.94, 95% confidence interval: 0.93-0.96]) measure of statin adherence. An approach of high-intensity statin therapy will lead to a significant practice change, as the majority of CVD patients are not on high-intensity therapy. However, this change may be associated with a very modest reduction in statin adherence compared with low- to moderate-intensity therapy that is unlikely to be of clinical significance.

The 2013 ACC/AHA cardiovascular prevention guidelines improve alignment of statin therapy with coronary atherosclerosis as detected by coronary computed tomography angiography

The recently released 2013 ACC/AHA guidelines for management of blood cholesterol have substantially increased the number of adults who are eligible for preventive statin therapy. We sought to determine whether eligibility for statin therapy as determined by the 2013 ACC/AHA guideline recommendation is better aligned with the actual presence of coronary artery disease (CAD) as detected by coronary CT angiography (CCTA) when compared to prior guidelines including the 2004 NCEP ATP III and 2011 ESC/EAS guidelines.In this secondary analysis of the prospective observational ROMICAT I (Rule Out Myocardial Infarction with Computer Assisted Tomography) cohort study, we included all men and women aged 40–79 years presenting with acute chest pain but not diagnosed with acute coronary syndrome nor on admission statin. Based on risk factor assessment and lipid data, we determined guideline-based eligibility for statin therapy by the 2013 ACC/AHA, the 2004 NCEP ATP III, and the 2011 ESC/EAS guidelines. We determined the presence and severity of CAD as detected by CCTA.The 2013 ACC/AHA algorithm identified nearly twice as many individuals as eligible for statins (n = 77/189; 41%) as compared to the 2004 ATP III criteria: (n = 41/189; 22%), (p < .0001) In addition, the 2013 ACC/AHA guidelines were more sensitive for treatment of CCTA-detected CAD than the 2004 ATP III guidelines [53.4% (42.5–64.1) vs 27.3% (18.3–37.8), p < .001] and the 2011 ESC/EAE guidelines [53.4% (42.5–64.1) vs 34.1% (24.3–45.0), p < .001]. However, the specificity of these guidelines was modestly reduced compared to the 2004 ATP III guidelines [70.3 (60.4–79.0) vs 83.2 (74.4–89.9), p < .001] and the 2011 ESC/EAE guidelines [70.3 (60.4–79.0) vs 86.1 (77.8–92.2), p < .001], suggesting increased treatment of subjects without CCTA-detected CAD. Overall, the 2013 ACC/AHA guidelines are more sensitive to identify patients who have CAD detected by CCTA eligible for statin therapy as compared with prior guidelines, with an acceptable trade-off in specificity for recommending statin therapy in those without CAD.

A look at statin cost-effectiveness in view of the 2013 ACC/AHA cholesterol management guidelines.

The 2013 cholesterol management guidelines presented a major shift in recommendations on which patients at risk of cardiovascular disease should be treated and how to treat them. Implementation of the guidelines is estimated to increase substantially the number of people who would be eligible for statin therapy. As the medical community considers the broad population impact of the new cholesterol guidelines, the issue of cost-effectiveness plays a role. This review covers the basic fundamentals of cost-effectiveness analysis and summarizes the key cost-effectiveness studies that relate to the new cholesterol guidelines.

Merits and potential downsides of the 2013 ACC/AHA cholesterol management guidelines

New guidelines from the American College of Cardiology and the American Heart Association on cholesterol management introduced substantial changes from the previous Adult Treatment Panel III guidelines and generated an immediate storm of controversy upon their release in November 2013. Four categories of individuals that can benefit from statin therapy, including three high-risk groups, have been identified. The fourth category of primary prevention has proven to be the most contentious, with criticism centering on the algorithm used to estimate ten-year risk for atherosclerotic cardiovascular disease and the optimal threshold for statin therapy. Although the risk assessment algorithm can be further refined, it represents an improvement from the previous calculator since it better captures risk in women and African Americans. However, the elimination of lipid targets in the new guidelines discounts a wealth of clinical trial and epidemiological evidence indicating that, with regards to low-density lipoprotein cholesterol, “lower is better.” Recommendations regarding the use of nonstatin drugs, while appropriate, could potentially be revised in the future. In general, the new guidelines stress the necessity of addressing the multiple factors that contribute to cardiovascular risk, and they provide a valuable opportunity for physicians to address the importance of lifestyle modifications to lower a patient's overall risk.

Atherosclerotic Cardiovascular Disease Risk and Evidence-based Management of Cholesterol.

An elevated level of low-density lipoprotein cholesterol is directly associated with development of atherosclerotic cardiovascular disease, which may present as coronary heart disease, stroke, and peripheral arterial disease. The new cholesterol management guidelines from the American College of Cardiology and the American Heart Association aim to address a comprehensive approach to prevent and reduce the risk of atherosclerotic cardiovascular disease. The new guidelines recommend initiation of heart healthy lifestyle modifications and 3-hydroxy-3-methylglutaryl coenzyme-A reductase inhibitor (“statin”) therapy in individuals who are at a high risk for atherosclerotic cardiovascular disease. It is estimated that these guidelines could result in “statin” therapy for one in every three adults in the United States. This article presents a review of the current cholesterol management guidelines, recommendations from relevant randomized controlled trials and meta-analyses obtained from the searches in Medline/PubMed and Cochrane Database of Systematic Reviews, and publications from the Centers for Disease Control and Prevention, the Centers for Medicare and Medicaid Service, and the United States Preventive Services Task Force.

Understanding cholesterol: high is bad but too low may also be risky – is low cholesterol associated with cancer?

Cholesterol (CH) is a vital component of cell membranes and of their function. It is entirely justified to warn against haphazard aggressive CH lowering, especially now, when more effective CH-modifying medications are entering the market. Enormous success in lowering the human toll of atherosclerosis and cardiovascular disease (CVD) by treating abnormally elevated lipids may be off set by the therapeutic risk. There are warning reports that low cholesterol is associated with malignity. There is a pressing need to evaluate all reports related to the risk of low CH body stores. New cholesterol management guidelines presented by American professional cardiology societies in November 2013 have reinforced the need to critically evaluate the management with statins and with other CH lowering medications (Tab. 1, Fig. 3, Ref. 58). total cholesterol (CH), low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C), cardiovascular disease (CVD), hydroxy-methylglutaryl coenzyme A reductase (HMGCR), randomized control trial (RCT), cancer, statin, low cholesterol risk, lipid treatment guideline.

Impact of Switching Treatment From Rosuvastatin to Atorvastatin on Rates of Cardiovascular Events

BackgroundNow that generic atorvastatin has become available, a process of switching from rosuvastatin to atorvastatin may occur and could persist until the patent on branded rosuvastatin expires. It is important to understand the impact that such therapy may have on patients’ cardiovascular (CV) health. ObjectivesThis simulated study estimates the impact of switching patients treated with rosuvastatin to atorvastatin on rates of CV events over a 5-year period. MethodsA study of 50,038 virtual dyslipidemic patients aged 45 to 70 years was conducted using the Archimedes model. Virtual patients were created based on the profiles of patients in the National Health and Nutrition Examination Survey (NHANES). Statin treatment models were constructed based on data from published studies, including STELLAR, JUPITER, CARDS, ASCOT, and TNT. Patients were started on a dose of rosuvastatin based on their ATP III low-density lipoprotein cholesterol (LDL-C) goal and the distributions of statin use observed in US pharmacy claims data. Patients were monitored for 5 years, during which time they received regular visits with the opportunity to increase their dosage if they were above their LDL-C goal. In the experimental arm, patients were switched from rosuvastatin to atorvastatin at the first clinic visit 6 weeks after initiating rosuvastatin (using an atorvastatin dose twice the rosuvastatin milligram-dose). No switching occurred in the control arm, and patients were titrated as necessary per ATP III cholesterol management guidelines. The rate of first occurrence of a major adverse cardiovascular event (MACE; myocardial infarction, stroke, and/or cardiovascular-related death) over the 5-year period was estimated for each study arm. ResultsAfter 5 years, in the atorvastatin-switched arm compared with continuing rosuvastatin, 4.8% fewer patients reached goal (87% vs 91%, respectively). The 5-year relative risk for MACE with switching was 1.109 (95% CI, 1.092–1.127), and the number needed to harm (NNH) to incur 1 additional MACE over 5 years was 262, favoring treatment with rosuvastatin. In diabetic individuals who were switched to atorvastatin, the 5-year relative risk for MACE was 1.121 (95% CI, 1.091–1.151), and the NNH over 5 years was 195, indicating greater risk in diabetic individuals. The results were insensitive to adherence rates and LDL-C goal values. ConclusionsThis study found that switching from rosuvastatin to atorvastatin led to fewer patients attaining LDL-C goal and a greater risk for MACE.

AHA-ACC Leaders Stand by Expanded Statin Recommendations

AHA-ACC Leaders Stand by Expanded Statin Recommendations