The newly released ACC/American Heart Association (AHA) guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults  expanded the indications for statin therapy for primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD) in higher risk patients. According to a study published March 19 in the New England Journal of Medicine, this expansion "would increase the number of adults [in the U.S.] who would be eligible for statin therapy by 12.8 million, with the increase seen mostly among older adults without cardiovascular disease."

The study looked at 3,773 adults between the ages of 40 and 75 years from the National Health and Nutrition Examination Surveys of 2005 to 2010, and compared the patient profile of the new guideline to the patient profile of the guideline of the Third Adult Treatment Panel (ATP III). Results were extrapolated to the population of 115.4 million U.S. adults between the ages of 40 and 75 who have triglyceride levels below 400 mg per deciliter, and showed that with the new guideline, 56.0 million U.S. adults would receive or be eligible for statin therapy, as compared to 43.2 million with the ATP III guidelines. Further, the majority of this increase would occur in adults without cardiovascular disease, and the new recommendations have a larger effect in adults age 60 to 75.

The authors note that "the ATP III guidelines place more emphasis on levels of LDL cholesterol to select patients for statin therapy, whereas the new ACC/AHA guideline bases the recommendation solely on the 10-year predicted risk, as long as the LDL cholesterol level is 70 mg per deciliter or higher." According to the new ACC/AHA guideline, there is no evidence to support continued use of specific LDL-C and/or non-high-density lipoprotein cholesterol (non-HDL-C) treatment targets. Rather, the appropriate intensity of statin therapy should be used to reduce risk in those most likely to benefit.

Moving forward, "the increased number of adults who would be newly eligible for statin therapy suggests higher treatment rates among those expected to have further cardiovascular events, but also an increased number of adults receiving therapy who are not expected to have events," the authors conclude. They add that the new guideline has "the potential to increase the net number of new statin prescriptions by 12.8 million, including 10.4 million for primary prevention."

"For those concerned that risk calculation using the ACC/AHA Pooled Cohort equations might overestimate risk, the panel found benefit for moderate intensity statin therapy in individuals with a five percent to < 7.5 percent 10-year ASCVD risk," note Neil J. Stone, MD, FACC, Jennifer Robinson, MD, MPH and David C. Goff, Jr., MD, PhD, in a Cardiology article. "Importantly, the risk discussion can point to other causes of risk, such as cigarette smoking and hypertension that require immediate attention. However, treatment of blood pressure and smoking cessation do not eliminate increased ASCVD risk over the near term and statin therapy should still be considered. It is worth noting that from 65 to 75 years, age may elevate risk into the statin treatment range without severe elevations of other risk factors. Nonetheless, individuals in this age range are still at increased risk of ASCVD in the 10-year time frame and have been shown to experience significant ASCVD risk reduction benefits without an excess of adverse events with statin therapy. After age 75, comorbidities, patient preferences, and safety considerations play a larger role in the decision to initiate statin therapy for primary prevention."

Keywords: Atherosclerosis, Risk Reduction Behavior, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Comorbidity, Risk Factors, Primary Prevention, Cholesterol, Secondary Prevention, Cardiovascular Diseases, Patient Preference, Nutrition Surveys, Hypertension, Smoking Cessation