Population Effect of Differences in Cholesterol Guidelines in Eastern Europe and the United States

Abstract

IMPORTANCE The American College of Cardiology/American Heart Association (ACC/AHA) guidelines for management of blood cholesterol and current European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines differ in how they identify adults in need of statin therapy; furthermore, it is unclear how this difference translates into numbers and characteristics of patients recommended for treatment. OBJECTIVE To determine the impact of the ACC/AHA and ESC/EAS cholesterol guidelines when applied to a population-based sample. DESIGN, SETTING, AND PARTICIPANTS We utilized nationally representative data for all adults ages 40–65 from the 2007–2012 National Health and Nutrition Examination Surveys for the U.S. (n=3,055) and from the 2001 Nadciśnięnie Tętnicze w Polsce (NATPOL) survey for Poland (n=1,060). MAIN OUTCOME MEASURES The number and characteristics of adults recommended for statin therapy under ACC/AHA and ESC/EAS guidelines were evaluated, and characteristics compared between adults with discordant recommendations. RESULTS In the U.S., 43.8% (95% confidence interval [CI] 40.9–46.7%) of adults under ACC/AHA and 39.1% (95% CI 36.4–41.8%) under ESC/EAS would be recommended for statin therapy. In Poland, 49.9% (95% CI 46.9–52.9%) of adults would be recommended under ACC/AHA compared with 47.6% (95% CI 44.6–50.7%) under ESC/EAS. Among individuals free of cardiovascular disease (CVD) and not currently on statins, 11.0% of U.S. and 10.5% of Polish adults had discordant guideline recommendations. Compared to those recommended by ESC/EAS and not ACC/AHA, those recommended by ACC/AHA only had less chronic kidney disease (CKD); however, these individuals were also more likely to smoke, have lower high-density lipoprotein cholesterol levels, and higher predicted 10-year CVD risks. CONCLUSIONS AND RELEVANCE Despite differences in the ACC/AHA and EAS/ESC guidelines, the numbers of adults aged 40–65 recommended for cholesterol-lowering therapy under each guideline were similar when applied to nationwide representative samples from both the U.S. and Poland. Discordant recommendations were driven by differences in the risk equations used in the two guidelines and different recommendations for adults with CKD.

Unmet need for hypercholesterolemia care in 35 low- and middle-income countries: A cross-sectional study of nationally representative surveys

“…Finally, we chose to define hypercholesterolemia and achieving control based on the ATP III guidelines due to their frequent use in the literature. However, these are relatively conservative in comparison to some national guidelines, as is apparent when examining the markedly lower cascade performance when applying AHA/ACC guidelines (see S1C Fig) . The comparability of countries is generally limited by a lack of universally used guidelines, as different guidelines are applied across countries and clinical settings and may even include geographical parameters, as is the case in the European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS) guidelines [59,60]. Despite this, such a comparison still offers important insights into national and global care gaps and can be used for identifying effective policy as well as serve as markers of progress in tackling the burden of hypercholesterolemia.…”

The extent to which statins have improved cardiovascular outcomes: Lessons from randomized trials and observational studies of “real world” practice in people with diabetes

“…However, ESC/EAS guidelines acknowledge that different LDL‐C goals have not been examined in RCTs. When applied to nationwide national samples similar numbers of adults were found to qualify for statin therapy in the United States and Poland regardless of the guideline used . The concordance is not similar in all countries of Europe.…”

“…When applied to nationwide national samples similar numbers of adults were found to qualify for statin therapy in the United States and Poland regardless of the guideline used. 19 The concordance is not similar in all countries of Europe. A modeling study utilizing data from the Copenhagen General Population Study found that ACC/AHA guidelines would prevent an estimated 34% ASCVD events compared to 13% using ESC/EAS guidelines in the study population.…”

Current guidelines on prevention with a focus on dyslipidemias

“…The authors note that a number of substantive and detailed reviews have been published with regards to these guidelines (4)(5)(6). We do not intend to replicate these but rather focus on certain core issues that may be relevant to day-to-day clinical practice.…”