Statin Benefit Groups Research Articles

The 2013 ACC/AHA Cholesterol Management Guideline: Clearing the Confusion from Noncontroversial Components.

The 2013 cholesterol-management guideline from the American College of Cardiology (ACC)/American Heart Association (AHA) was published in November 2013.1 On the basis of high-quality evidence and data from randomized controlled trials, this guideline recommends a risk–benefit discussion regarding statin therapy in 4 statin-benefit groups: patients with atherosclerotic cardiovascular disease (ASCVD); patients with low-density-lipoprotein cholesterol (LDL-C) levels ≥190 mg/dL; patients with diabetes mellitus of age 40 to 75 years; and patients with estimated 10-year ASCVD risk ≥7.5% on the basis of an ASCVD risk estimator derived from the pooled-cohort risk equation. Moderate- to high-intensity statin therapy is recommended for these patient groups. Moderate-intensity statin therapy is defined as statin therapy that lowers LDL-C 30% to <50%. High-intensity statin therapy lowers LDL-C ≥50%.

Retrospective Evaluation of ASCVD Risk and Statin Therapy Need in Nondiabetic Patients Based on the 2013 ACC/AHA Cholesterol Guidelines

Purpose: Study goal was to assess the impact of the 2013 American College of Cardiology and the American Heart Association (ACC/AHA) Cholesterol Guidelines on patients in the fourth statin benefit group which included patients aged 40 to 75 years, without diabetes or clinical atherosclerotic cardiovascular disease (ASCVD), and have an ASCVD score ≥7.5%. These patients could benefit from treatment interventions by a pharmacist. Methods: Patients were identified from electronic health records. A sample of 3503 patients was ascertained from having a lipid panel performed within the 12 months before November 1, 2013. Patients were excluded if we were unable to calculate 10-year ASCVD risk. Results: A total of 3203 patients were included, with 2008 not on statin therapy. Of those, 1507 (75%) had a 10-year ASCVD risk score <7.5% and 501 (25%) had a score > 7.5%. Patient characteristics leading to an increase in risk included advanced age, smoker, male, and hypertension treatment. Of 2008 nonstatin patients, there were 466 (23.2%) who fit criteria for initiation of moderate- or high-intensity statin. Conclusion: Widespread adoption of the 2013 ACC/AHA Cholesterol Guidelines will expand prescribing rates of statins. Implementing screening strategies may help identify patients who require treatment in this fourth statin benefit group. A pharmacist can be vital in screening patients, educating patients regarding the need for medication therapy, and monitoring for adherence in these new regimens.

Case-based educational intervention to assess change in providers' knowledge and attitudes towards the 2013 American College of Cardiology/American Heart Association Cholesterol Management Guideline

ObjectivePrior studies have shown provider-level knowledge gaps regarding the 2013 American College of Cardiology/American Heart Association guideline on the treatment of cholesterol and concerns about 10-year atherosclerotic cardiovascular disease (ASCVD) risk estimation. The effect of an educational intervention to mitigate knowledge gaps is unknown. MethodsWe developed a questionnaire and administered it to providers before (pre-training) and after (post-training) a case-based educational intervention across 6 sites in Texas. The intervention highlighted the key recommendations of the 2013 guideline and the differences from the prior guideline mainly using clinical-vignettes. Several practice pertinent items were also discussed. ResultsMost participants were providers-in-training (78%) in internal medicine (68%). Compared to pre-training, the post-training metrics were: 43% vs. 82% for providers' ability to identify 4 statin benefit groups; 47% vs. 97% for their awareness of the ASCVD risk threshold of ≥7.5% to initiate discussion about risks/benefits of statin therapy; 9% vs. 40% for awareness of differences between the Framingham and the ASCVD risk estimator; 26% vs. 78% for awareness of the definition of statin intensity; 35% vs. 62% for using a repeat lipid panel to document treatment response and adherence; and 46% vs. 81% for confidence in using the ASCVD risk estimator, respectively. ConclusionsA case-based educational intervention was associated with significant increase in providers' knowledge towards the 2013 cholesterol guideline, which could be related to the engaging nature of our intervention, using practice pertinent information and clinical vignettes. Such interventions could be useful in effective dissemination of the cholesterol guideline.

The Relationships Between the Arterial Stiffness Index Measured at the Radial Artery and Left Ventricular Diastolic Dysfunction in Asymptomatic High Risk Patients Without Atherosclerotic Cardiovascular Disease.

Arterial stiffness is associated with atherosclerosis and left ventricular (LV) diastolic function in general or hypertensive patients. However, the relationships between the arterial stiffness index measured at the radial artery and LV diastolic dysfunction in asymptomatic high-risk patients without atherosclerotic cardiovascular disease (ASCVD) have not been fully established.A total 532 statin-naïve patients (male:female ratio, 230:302, mean age, 56.0 ± 9.2 years) without ASCVD were enrolled from among subjects who simultaneously underwent transthoracic echocardiography and noninvasive semiautomated radial artery applanation tonometry from July 2011 to May 2014. Of these patients, 213 were categorized as the statin benefit group (Benefit) according to guidelines for blood cholesterol treatment, and the rest were placed in the nonbenefit control group (NoBenefit). Each group was subdivided into two groups (Y or N) according to antihypertensive medication administration. Thus, there were 4 groups: BenefitN (n = 80), BenefitY (n = 133), NoBenefitN (n = 251), and NoBenefitY (n = 68). There were significant differences in echocardiographic parameters of LV function and indices of arterial stiffness between the Benefit and NoBenefit groups. After adjusting for several risk factors, independent significant associations between echocardiographic parameters of LV diastolic function and arterial indices were identified with multivariate linear regression analysis in the Benefit patients.Parameters of arterial stiffness measured at the radial artery are associated with echocardiographic indices of LV diastolic function in asymptomatic high-risk patients without ASCVD. Therapies that prevent progression of arterial stiffness and reduce late-systolic pressure overload may help to reduce the prevalence of LV diastolic dysfunction in this population.

Algorithms for cardiovascular disease prevention

Prevention of coronary artery disease requires control of risk factors. It is not enough to take out guidelines, it is necessary to implement the guidelines. There are a number of studies which have shown that quite often guidelines are not followed.In this article, we have abstracted the essence of the guidelines into simple to follow algorithms so that they are easy to remember and also teach. For Cardiovascular risk reduction, general measures include stopping smoking, perform 150 minutes of moderate activity per week and take a low fat and low salt diet. For hypertension: All classes of drugs are suitable but generally (NICE 2011) Angiotensin receptor blockers or Angiotensin converting enzyme inhibitors for young ( 55 years, many with isolated systolic hypertension) Calcium channel blockers, diuretics if needed , are prefered. Combinations are used if monotherapy does not work. For dyslipidemia: Statin benefit groups are defined and manifest coronary artery disease and Diabetics above 40 years should get high dose statins. Lipid levels are only tested to look for compliance or further intensification of regime. Diabetes: Metformin is the drug of choice, Sulfonylureas can be used in combination. Glyptins are also safe and can be used. Other drugs should be used with the help of the endocrinologist.

Provider understanding of the 2013 ACC/AHA cholesterol guideline

Providers' understanding of the 2013 American College of Cardiology (ACC)/American Heart Association (AHA) cholesterol guideline in clinical practice is not known. We designed a questionnaire, which was administered to internal medicine, family practice, cardiology, and endocrinology providers at 21 venues across the United States. We compared responses between providers in training or practice and between specialists (cardiology and endocrinology) and nonspecialists (internal medicine and family practice). Response rate was 72.1% (543 of 725). About 43% of the providers in training and 48% of those in practice indicated having read the guideline. Almost 50% in each group were unable to identify the 4 statin benefit groups and a large proportion (41% in training and 49% in practice) were not aware of the ≥7.5% 10-year risk threshold for discussion regarding statin therapy. Most (∼85%) were unaware of the 4 outcomes assessed by the 10-year ASCVD risk equation. About 36% of the providers in training and 48% in practice could identify a patient with familial hypercholesterolemia and start a discussion regarding statin therapy. Only 27.6% of the providers in training and 40.4% in practice recommended repeating a lipid panel 6-8weeks after starting statins in a patient with recent myocardial infarction. Similar gaps were noted when comparing specialists to nonspecialists. Most providers do not completely understand the 2013 ACC/AHA cholesterol guideline. As an unintended consequence, providers are moving away from lipid testing to document response and adherence to statin therapy. Efforts are needed to address these gaps.

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 &lt;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 &lt;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.

Abstract 10341: Prevalence and Factors Associated With Statin Use Among a Nationally Representative Sample of US Adults - National Health and Nutrition Examination Survey, 2011-2012

Background: The 2013 AHA/ACC guidelines recommend the use of statins for adults ≤75 years who have clinical ASCVD (IA) and for primary prevention among persons aged 40 – 75 with diabetes mellitus and LDL btw 70 - 189mg/dl (IA). The aim of this study was to estimate the prevalence and likelihood of statin use among selected statin benefit groups. Methods: Using data from the National Health and Nutrition Examination Survey (NHANES) for the 2011 - 2012 cycle, we examined 5,319 adults aged 20 years and older. We estimated weighted frequencies and proportions with confidence intervals for the entire sample and for persons with diabetes and LDL ≥70 or a diagnosis of dyslipidemia, denoted statin benefit group 1 (SBG1) and for persons with history of ASCVD, statin benefit group 2 (SBG2). We constructed a multivariable logistic regression model to estimate the odds of statin use among persons in SBG1. All analyses were conducted using SAS survey procedures for complex sample data and evaluated at α=0.05. Results: Among persons in SBG1 (mean age: 61yrs), 59.5% (95% CI: 53.0 – 66.1), an estimated 10.6 million persons and 63.5% (95% CI: 55.6 – 71.4) of persons in SBG2 (mean age: 65yrs), an estimated 10.8 million persons were on a statin. A sub-population analysis among persons aged 40 – 75 showed statin use to be 58.8% (95% CI: 51.5 – 66.1) for persons in SBG1. Overall, an estimated 38.6 million Americans are on a statin, an increase from 24 million in 2003-2004. In adjusted models, uninsured persons and Hispanics compared to Whites were less likely to be on a statin. Conclusion: The prevalence of statin use among US adults has tripled since 1999-2000. However racial disparities and lack of insurance remain a barrier to statin use. Our study provides a baseline estimate of statin use in the noninstitutionalized civilian adult population just prior to the introduction of the new guidelines and provides a reference for evaluating the impact of the 2013 guidelines on statin utilization.

Circulation : Clinical Summaries

<i>Circulation</i> : Clinical Summaries

Treatment of dyslipidemia in diabetes. Should the lipid-management protocol which the ADA 2015 guideline recommends be used for Japanese as a reference?

This ADA guideline followed the concept of the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guideline [3], which had been settled in accordance with ‘‘the 2011 report of the Institute of Medicine on the development of trustworthy clinical guidelines’’ [4]. Briefly, the expert panels had asked critical questions, chosen and reviewed high-quality randomized controlled trials (RCTs) and reliable meta-analyses, and resolved the critical questions. Their precise analyses had identified ‘‘four statin benefit groups’’ which would benefit from management with statins, and diabetic patients were included among these groups. This identification of ‘‘four statin benefit groups’’ is a great advance in that physicians can easily identify patients requiring treatment for dyslipidemia. Besides this identification, the panels recommended administration of a fixed dose of the appropriate statin, leaving behind the ‘‘treat-to-target’’ protocol in which titration of agents is performed to achieve target lipid levels. The theoretical framework for this recommendation was: fixed doses of specific statins were used in the analyzed RCTs; and these RCTs did not utilize protocols in which agent dose titration was performed to target specific LDL-C or nonHDL-C levels.

To what extent do high-intensity statins reduce low-density lipoprotein cholesterol in each of the four statin benefit groups identified by the 2013 American College of Cardiology/American Heart Association guidelines? A VOYAGER meta-analysis.

The 2013 American College of Cardiology and American Heart Association (ACC/AHA) guidelines identify four patient groups who benefit from moderate- or high-intensity statin treatment; those with: 1) atherosclerotic cardiovascular disease (ASCVD); 2) low-density lipoprotein cholesterol (LDL-C) ≥190mg/dl; 3) diabetes; or 4) a 10-year ASCVD risk ≥7.5%. High-intensity statins, anticipated to reduce LDL-C by≥50%, were identified as rosuvastatin 20-40mg and atorvastatin 40-80mg. Individual patient data (32,258) from the VOYAGER database of 37 studies were used to calculate least-squares mean (LSM) percentage change in LDL-C during 8496 patient exposures to rosuvastatin 20-40mg, and atorvastatin 40-80mg in the four patient benefit groups. LSM percentage reductions in LDL-C with rosuvastatin 20 and 40mg were greater than with atorvastatin 40mg, overall and in each statin benefit group, and with rosuvastatin 40mg were greater than with atorvastatin 80mg overall and in three of the four benefit groups (all p<0.05). For example, in the ASCVD group, 40%, 59%, 57% and 71% of patients treated with atorvastatin 40mg, atorvastatin 80mg, rosuvastatin 20mg and rosuvastatin 40mg, respectively, had a ≥50% reduction in LDL-C. The choice and dose of statin have an impact both on the percentage LDL-C reduction and achievement of ≥50% reduction in LDL-C, overall and within each of the four statin benefit groups outlined by the 2013 ACC/AHA guidelines. This may be of importance for clinicians in their choice of treatment for individual patients.

Abstract 154: Trends in the Use of Lipid Lowering Therapies and LDL-C Levels in the US Adult Population with High Cardiovascular Risk Between 2003-2012

Background: Cardiovascular disease (CVD) remains the largest cause of mortality worldwide, and will claim an estimated 20 million lives annually by 2030. For those at highest risk from CVD, lipid lowering therapies (LLT), including statins, are the mainstay of treatment. Despite the widespread use of LLTs, it remains unclear whether greater intervention is required to reduce LDL-C among those at high risk. Objectives: We examined the utilization patterns of LLTs between 2003-2012, and the proportion of LLT users with LDL&lt;70 mg/dL among those in the 4 statin benefit groups (SBGs) defined by the 2013 American College of Cardiology and the American Heart Association (ACC/AHA) guidelines. Methods: We used data from National Health and Nutrition Examination Survey (NHANES) between 2003-2012 to assess trends in LLTs use and percent of users with LDL-C&lt;70 mg/dL among adults ≥18 years old in the US population who met the criteria for the 4 SBGs. We calculated frequencies, means, and percents that were weighted using NHANES-provided population weights to obtain population estimates. We conducted linear trend tests to assess whether changes in estimates were statistically significant over time. Results: The percent of adults in the 4 SBGs who used LLTs increased from 31% to 47% (p&lt;0.001) between 2003-2012. In particular, the two SBGs with a statistically significant increase in LLTs between 2003-2012 were the group with atherosclerotic cardiovascular disease (ASCVD) (p&lt;0.001) and the group with type 2 diabetes (p=0.046). Among LLT users overall, the percent with LDL-C&lt;70 mg/dL increased from 11% in 2003-2004 to 22% in 2011-2012 (p&lt;0.001). The type 2 diabetes SBG was the only one of the 4 SBGs to have a significant improvement from 2003-2012 in the percent of LLT users with LDL-C &lt; 70 mg/dL (p=0.014). In 2011-2012, 46% of the LLT users in the type 2 diabetes SBG had an LDL-C &lt;70 mg/dL. The other 3 SBGs experienced no significant change in the percent of LLT users with LDL-C &lt; 70 mg/dL, even when there was an increase in the use of LLTs in that group. For instance, among people with ASCVD, 73% used LLTs in 2011-2012, yet only 20% of these users had LDL-C&lt;70 mg/dL. Conclusions: Despite an increase in the number of people considered at high risk by the ACC/AHA guidelines and the significant rise in LLT use between 2003-2012, few LLT users have LDL-C levels less than 70 mg/dL. With recent evidence showing that lower LDL-C levels confer the greatest decreases in risk of cardiac events, a significant treatment gap and opportunity to intensify treatment remains in the US adult population at high cardiovascular risk.

Abstract 134: Unmet Need in Hyperlipidemia

Background: Cardiovascular disease (CVD) remains the largest driver of mortality worldwide, with an annual global estimate of 20 million deaths by 2030. Lipid lowering therapies (LLT) including statins have become a mainstay of treatment for those at risk for CVD. Similarly, for approximately 20 years, treatment for those with atherosclerotic disease (ASVCD) has mainly involved the use of LLTs to lower levels of low density lipoprotein (LDL-C). Despite the widespread use of LLTs, it remains unclear whether greater intervention is required to reduce LDL-C to safe levels among those at high risk. Objectives: We examined the utilization patterns of LLTs between 2003-2012, and the proportion of LLT users with LDL&lt;70 mg/dL among those in the 4 statin benefit groups defined by the American College of Cardiology and the American Heart Association (ACC/AHA). Methods: We used data from NHANES between 2003-2012 to assess trends in LLTs use and percent of users with LDL-C&lt;70 mg/dL among adults ≥18 years old in the US population who met the criteria for the 4 statin benefits groups. We calculated frequencies, means, and percents that were weighted to obtain population estimates. We conducted linear trend tests to assess whether changes in estimates were statistically significant over time. Results: The number of adults ≥18 years old in the US who belonged to the 4 statin benefit groups increased from 57,260,635 (26.7%) in 2003-2004 to 64,479,875 (27.9%) in 2011-2012. The percent of adults in these 4 statin benefit groups who used LLTs increased from 30.8% to 47.1% (p&lt;0.001) between 2003-2012. Among LLT users, the percent with LDL-C&lt;70 mg/dL increased from 11.0% in 2003-2004 to 21.9% in 2011-2012 (p&lt;0.001). In 2011-2012, the percent of LLT users with LDL-C &lt;70 mg/dL in the 4 statin benefit groups ranged from 0% to 46%. Among people at highest risk (with ASCVD), 72.9% used LLTs in 2011-2012, and only 20% of these users had LDL-C&lt;70 mg/dL. Conclusions: Despite an increase in the number of people considered at high risk by the ACC/AHA guidelines and the significant rise in LLT use between 2003-2012, the majority of LLT users have LDL-C levels over 70 mg/dL. Given the recent evidence that lower LDL-C levels confer the greatest decreases in risk of cardiac events, a significant unmet need exists for greater intervention in order to effectively decrease LDL-C to safe levels in the US adult population.

Abstract 232: Cost-effectiveness Analysis of Lipoprotein Subfraction Testing in Patients at Intermediate Risk of Cardiovascular Events

Background: The 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Disease (CVD) in Adults defined 4 patient groups who would benefit from statin therapy. For patients who are not classified into a statin benefit group, and have an estimated 10-year CVD risk between 5% and 7.5%, the guidelines suggest that additional risk factors may be considered to inform moderate-intensity statin treatment decisions. Low density lipoprotein concentration (LDL-P) has been shown to be associated with incident CVD events among patients with &lt;7.5% 10-year risk after adjusting for established risk factors. Objectives: To assess the cost-effectiveness of using LDL-P for risk assessment as an aid in making statin treatment decisions in patients with an estimated 10-year CVD risk of 5% to 7.5%. Methods: We conducted a cost-effectiveness analysis using a Markov model that assessed patient healthcare costs and outcomes from a payer perspective over a 5 year time horizon. A usual care strategy was compared with an LDL-P test-and-treat strategy in a hypothetical intermediate risk population_those with an estimated 10-year CVD risk of 5% to 7.5%. The test-and-treat strategy entailed testing LDL-P levels in 10,000 patients and treating only those in the top decile of LDL-P _those who would be reclassified above estimated 7.5% 10-year risk_with a moderate-dose statin therapy. Future cost and utilities were derived from published literature and were discounted at 3% annually. Single- and multi-variable sensitivity analyses were conducted to investigate the effect of the base-case assumptions on the difference in costs and quality-adjusted life years (QALYs) between the two strategies. Results: Compared with a usual care strategy, LDL-P testing of 10,000 patients followed by moderate-intensity statin therapy of patients in the top decile of LDL-P resulted in 17 fewer patients with CVD events, cost savings of more than $300,000, and about 13 additional QALYs over a 5 year horizon. Conclusions: CVD risk assessment by LDL-P testing of patients with estimated 10-year CVD risk of 5% to 7.5%, who were not classified into a statin benefit group, may be an event-reducing and a cost-saving strategy compared with usual care.

Posicionamiento del Comité Español Interdisciplinario de Prevención Cardiovascular y la Sociedad Española de Cardiología en el tratamiento de las dislipemias. Divergencia entre las guías europea y estadounidense

The publication of the 2013 American College of Cardiology/American Heart Association guidelines on the treatment of high blood cholesterol has had a strong impact due to the paradigm shift in its recommendations. The Spanish Interdisciplinary Committee for Cardiovascular Disease Prevention and the Spanish Society of Cardiology reviewed this guideline and compared it with current European guidelines on cardiovascular prevention and dyslipidemia management.The most striking aspect of the American guideline is the elimination of the low-density lipoprotein cholesterol treat-to-target strategy and the adoption of a risk reduction strategy in 4 major statin benefit groups. In patients with established cardiovascular disease, both guidelines recommend a similar therapeutic strategy (high-dose potent statins). However, in primary prevention, the application of the American guidelines would substantially increase the number of persons, particularly older people, receiving statin therapy. The elimination of the cholesterol treat-to-target strategy, so strongly rooted in the scientific community, could have a negative impact on clinical practice, create a certain amount of confusion and uncertainty among professionals, and decrease follow-up and patient adherence. Thus, this article reaffirms the recommendations of the European guidelines. Although both guidelines have positive aspects, doubt remains regarding the concerns outlined above. In addition to using risk charts based on the native population, the messages of the European guideline are more appropriate to the Spanish setting and avoid the possible risk of overtreatment with statins in primary prevention.

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.

The New ACC/AHA Cardiovascular Risk Guidelines: Impact and Controversies

The new American College of Cardiology/American Heart Association (ACC/AHA)2 guidelines for cardiovascular disease (CVD) risk assessment and treatment (1), released >6 months ago, have engendered much controversy. A recent New England Journal of Medicine article (2) has estimated the impact of the new guidelines on the use of statins in the US. Extrapolating from the National Health and Nutrition Examination Survey population, the new guidelines could result in treating approximately 56 million Americans with statins, or 12.8 million more people than would have been treated according to the older Adult Treatment Panel III (ATP-III) guidelines (3). Approximately half the population between the ages of 40 and 75 years would be eligible for statins under the new guidelines, compared with about 37.5% under ATP-III. Given that CVD accounts for about a third of all mortality, and that the lifetime incidence of CVD is about 60%, treating more patients with statins is perhaps reasonable. Furthermore, it is estimated that the new guidelines may reduce CVD by about a half million events every 10 years (2). So why are the new ACC/AHA guidelines controversial? Three of the four major identified patient groups that could benefit from statins are similar between the ACC/AHA and ATP-III guidelines. The first statin benefit group for both sets of guidelines includes individuals with known CVD. In contrast to the ATP-III guidelines, which recommend statin therapy for individuals with LDL cholesterol (LDL-C) ≥100 mg/dL (2.59 mmol/L), the ACC/AHA guidelines no longer use LDL-C as a statin treatment criterion for this patient group. In the second statin benefit group, which includes individuals with LDL-C ≥190 mg/dL (4.92 mmol/L), the recommended treatment is identical in both guidelines. For the third statin benefit group, which includes those with diabetes, the two guidelines slightly differ in their LDL-C inclusion criteria, LDL-C ≥70 …

Guías en el manejo de la dislipemia

The AHA/ACC 2013 guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular disease (ASCVD) in adults contains major differences with the previous ESC/EAS 2011 guidelines and the remaining international guidelines, which has generated major controversies. The AHA/ACC document has developed a new model for estimating cardiovascular risk for primary prevention which is not comparable with the SCORE recommended in the European guidelines. This guideline does not establish a fixed target for low-density lipoprotein cholesterol (LDLc). Instead, it identifies 4 major statin benefit groups at risk for the development ASCVD, who should receive low-, moderate-, and high-intensity statin therapy to reduce LCLc. In contrast, the European guidelines maintain LDLc as the main treatment target and non-high-density lipoprotein cholesterol as a secondary treatment target. The document recommends calculating cardiovascular risk for the overall treatment of patients with dyslipidemia according to 4 risk levels (low, moderate, high, and very high), establishes LDLc treatment targets, and recommends a statin-based therapeutic strategy and other, lipid-lowering strategies, aimed at achieving these targets.The American guidelines cannot be extrapolated to the European population. Target-based treatment, as recommended in the EAS/ESC guidelines, is the best strategy for Europe. In Spain, the Primary Care Guidelines of the Spanish Society of Family and Community Medicine (semFYC) and the Spanish Society of Primary Care Physicians (SEMERGEN) are based on the European recommendations. Finally, the Spanish Society of Arteriosclerosis (SEA), SEMERGEN, semFYC and the Spanish Society of General Medicine (SEMG) are reaching a consensus on the approach and management of patients with atherogenic dyslipidemia in primary care.

Posicionamiento del Comité Español Interdisciplinario de Prevención Cardiovascular y la Sociedad Española de Cardiología en el tratamiento de las dislipemias. Divergencia entre las guías europea y estadounidense

The publication of the 2013 American College of Cardiology/American Heart Association guidelines on the treatment of high blood cholesterol has had a strong impact due to the paradigm shift in its recommendations. The Spanish Interdisciplinary Committee for Cardiovascular Disease Prevention and the Spanish Society of Cardiology reviewed this guideline and compared it with current European guidelines on cardiovascular prevention and dyslipidemia management.The most striking aspect of the American guideline is the elimination of the low-density lipoprotein cholesterol treat-to-target strategy and the adoption of a risk reduction strategy in 4 major statin benefit groups. In patients with established cardiovascular disease, both guidelines recommend a similar therapeutic strategy (high-dose potent statins). However, in primary prevention, the application of the American guidelines would substantially increase the number of persons, particularly older people, receiving statin therapy. The elimination of the cholesterol treat-to-target strategy, so strongly rooted in the scientific community, could have a negative impact on clinical practice, create a certain amount of confusion and uncertainty among professionals, and decrease follow-up and patient adherence. Thus, this article reaffirms the recommendations of the European guidelines. Although both guidelines have positive aspects, doubt remains regarding the concerns outlined above. In addition to using risk charts based on the native population, the messages of the European guideline are more appropriate to the Spanish setting and avoid the possible risk of overtreatment with statins in primary prevention.Full English text available from:www.revespcardiol.org/en

Spanish Interdisciplinary Committee for Cardiovascular Disease Prevention and the Spanish Society of Cardiology Position Statement on Dyslipidemia Management. Differences Between the European and American Guidelines

The publication of the 2013 American College of Cardiology/American Heart Association guidelines on the treatment of high blood cholesterol has had a strong impact due to the paradigm shift in its recommendations. The Spanish Interdisciplinary Committee for Cardiovascular Disease Prevention and the Spanish Society of Cardiology reviewed this guideline and compared it with current European guidelines on cardiovascular prevention and dyslipidemia management.The most striking aspect of the American guideline is the elimination of the low-density lipoprotein cholesterol treat-to-target strategy and the adoption of a risk reduction strategy in 4 major statin benefit groups. In patients with established cardiovascular disease, both guidelines recommend a similar therapeutic strategy (high-dose potent statins). However, in primary prevention, the application of the American guidelines would substantially increase the number of persons, particularly older people, receiving statin therapy. The elimination of the cholesterol treat-to-target strategy, so strongly rooted in the scientific community, could have a negative impact on clinical practice, create a certain amount of confusion and uncertainty among professionals, and decrease follow-up and patient adherence. Thus, this article reaffirms the recommendations of the European guidelines. Although both guidelines have positive aspects, doubt remains regarding the concerns outlined above. In addition to using risk charts based on the native population, the messages of the European guideline are more appropriate to the Spanish setting and avoid the possible risk of overtreatment with statins in primary prevention.