November 11, 2019
By Marilynn Larkin
NEW YORK (Reuters Health) - Following publication of the 2013 American College of Cardiology/American Heart Association (ACC/AHA) cholesterol guidelines, lipid and lipoprotein levels among US adults seem to have declined, whereas awareness of high cholesterol levels among those at risk - a key point of the guidelines - has remained stable, researchers say.
"The focus of lipid management shifted from the previous 'titration to a goal' to a 'risk-based approach' after the publication of the 2013 ACC/AHA cholesterol guideline, and has continued in the (2018) guideline," Dr. Pankaj Arora of the University of Alabama at Birmingham told Reuters Health by email.
The risk-based approach "ensured that more U.S. adults without clinical cardiovascular disease, but with a higher risk of developing it, benefit from (the) guidelines," he said.
Dr. Arora and colleagues used U.S. National Health and Nutrition Examination Survey (NHANES) data collected between 2005-2006 and 2015-2016 (i.e., before and after the 2013 guideline) to assess trends in lipid and lipoprotein levels in more than 32,000 adults.
As reported online November 11 in the Journal of the American College of Cardiology, among those taking lipid-lowering medication:
- Mean age-adjusted total cholesterol declined from 206 mg/dl in 2005-2006 to 191 mg/dl in 2013-2014, with an additional drop to 187 mg/dl in 2015-2016.
- Mean age-adjusted low-density lipoprotein cholesterol decreased from 122 mg/dl in 2005-2006 to 107 mg/dl in 2013-2014 to 101 mg/dl in 2015-2016.
- The geometric mean of triglyceride levels decreased from 176 mg/dl in 2005-2006 to 122 mg/dl in 2013-2014.
Overall, high-density lipoprotein cholesterol levels did not change during the study period.
Further, among adults eligible for statin treatment according to the 2013 ACC/AHA guideline criteria, the proportion who reported being told they had high cholesterol (awareness of high cholesterol levels) rose from 63.6% in 2005-2006 to 69.4% in 2011-2012.and remained unchanged at about 69% from 2011-2012 through 2015-2016.
The proportion taking a statin increased from 41.3% in 2005-2006 to 49.2% in 2015-2016.
The proportion of U.S. adults with atherosclerotic cardiovascular disease (ASCVD) who were aware of their high cholesterol levels increased from 51.5% in 2005-2006 to 67.7% in 2015-2016; however, there was no change among adults with an ASCVD risk of 7.5% or greater.
Among those with diabetes, awareness of high cholesterol levels was about 74% during the study period. Statin use in this group increased from 48.3% in 2005-2006 to 60.2% in 2015-2016.
Among participants with a 10-year predicted ASCVD risk of 7.5% or greater - a group the guideline said would have the most benefit - statin use increased from 27.9% in 2005-2006 to 36.7% in 2013-2014; however, it decreased to 32.5% in 2015-2016.
Improving patients' perception of statin safety by alleviating fears of side effects and targeting educational interventions at patients and health care providers can help improve guideline dissemination, Dr. Arora noted.
Dr. Howard Weintraub, Clinical Director, NYU Center for the Prevention of Cardiovascular Disease in New York City, commented to Reuters Health, "The 2013 guidelines represented a complete unraveling of the lipid-lowering mentality from 2004, which was treating to target. A lot of clinicians became confused, because it was not clear why the change was made, and they thought it was wrong. The result is that they did nothing."
"I think that's what we're witnessing in these findings," he said in a phone interview. "Many people thought it wasn't right to increase the pool of people who are statin-eligible, and because of the change, they didn't know what to believe."
"However, we now have the 2018 guidelines from the AHA/ACC, which remain similar to 2013," he noted. (http://bit.ly/36V9rIE) "And, the Europeans came out with guidelines six weeks ago that are even more aggressive than ours." (http://bit.ly/2rAuNLv) ]
"People should be aware that new targets for lowering have been identified, particularly with the newer PCSK9 studies, which can be extrapolated to statins in patients who are able to get there," he added. "Whether an individual is getting there by eating and dieting or using statins or adding PCSK9 inhibitors, it appears that achieving an LDL that's lower than we previously contemplated, but now can achieve, has benefit," Dr. Weintraub concluded.
J Am Coll Cardiol 2019.(c) Copyright Thomson Reuters 2019. Click For Restrictions - https://agency.reuters.com/en/copyright.html