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Comment & Response
January 11, 2017

Statin Eligibility Under American and European Cholesterol Guidelines

Author Affiliations
  • 1Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
JAMA Cardiol. Published online January 11, 2017. doi:10.1001/jamacardio.2016.5080

To the Editor Extrapolating from cross-sectional surveys in the United States and Poland, Lee et al1 compared statin eligibility under guidelines from the American College of Cardiology/American Heart Association (ACC/AHA)2 and the European Society of Cardiology/European Atherosclerosis Society (ESC/EAS)3 and concluded, “Despite differences in the ACC/AHA and EAS/ESC guidelines, the numbers of adults aged 40 to 65 years recommended for cholesterol-lowering therapy under each guideline were similar when applied to nationwide representative samples from both the United States and Poland.”

This conclusion is misleading regarding risk-based primary prevention, as statin eligibility primarily depends on age and absolute risk estimated by the American Pooled Cohort Equations (PCE) and the European Systematic Coronary Risk Evaluation (SCORE) models. The comparison favors a priori the ESC/EAS guidelines by (1) restricting the age range to 40 to 65 years (those older than 65 years are only eligible by PCE), (2) including both class I and IIa SCORE-based recommendations but only class I PCE-based recommendations, and (3) declaring the United States a high-risk country by European standards. Nevertheless, despite boosting the ESC/EAS guidelines, only 3.5 million Americans were eligible for SCORE-based statin therapy in contrast to 9.2 million Americans using the PCE-based class I recommendation for statin therapy (Figure 1A1).

Declaring the United States a high-risk country is critically important and not in agreement with the ESC definition of high risk—cardiovascular mortality rates of more than 225 in men and more than 175 in women per 100 000 in 2012, age-adjusted to the World Health Organization World Standard Population.4,5 For the United States, such age-adjusted mortality rates are 170 in men and 108 in women per 100 000,5 clearly indicating that, in contrast to Poland, the United States is not a high-risk country as defined by the ESC guidelines. Among 97.9 million Americans, 39.1% were eligible for statin therapy under the ESC/EAS guidelines, of whom 3.5 million qualified for risk-based statin therapy using the SCORE model intended for high-risk countries (Figure 1A1). However, according to the sensitivity analysis, only 36.1% (2.9 million fewer people) would have qualified for statin therapy if the SCORE model intended for low-risk countries had been used. Consequently, the number of Americans eligible for SCORE-based statin therapy dropped by 2.9 million, from 3.5 million to only 0.6 million. Hence, 15-fold more apparently healthy at-risk Americans aged 40 to 65 years (9.2 million vs 0.6 million) would qualify for statin therapy under the ACC/AHA guidelines compared with the ESC/EAS guidelines if the United States had been correctly classified as a low-risk country.

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Article Information

Corresponding Author: Erling Falk, MD, DMSc, Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Blvd, DK-8200 Aarhus, Denmark (erling.falk@clin.au.dk).

Published Online: January 11, 2017. doi:10.1001/jamacardio.2016.5080

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

References
1.
Lee  JC, Zdrojewski  T, Pencina  MJ,  et al.  Population effect of differences in cholesterol guidelines in Eastern Europe and the United States. JAMA Cardiol. 2016;1(6):700-707.
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2.
Stone  NJ, Robinson  JG, Lichtenstein  AH,  et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines.  2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(25, pt B):2889-2934.
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Reiner  Z, Catapano  AL, De Backer  G,  et al; European Association for Cardiovascular Prevention & Rehabilitation; ESC Committee for Practice Guidelines (CPG) 2008-2010 and 2010-2012 Committees.  ESC/EAS Guidelines for the management of dyslipidaemias: the Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS). Eur Heart J. 2011;32(14):1769-1818.
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Piepoli  MF, Hoes  AW, Agewall  S,  et al; Authors/Task Force Members.  2016 European Guidelines on cardiovascular disease prevention in clinical practice: the Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts) developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J. 2016;37(29):2315-2381.
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World Health Organisation. WHO Global Health Observatory data repository: cardiovascular diseases, deaths per 100 000. http://apps.who.int/gho/data/node.main.A865CARDIOVASCULAR?lang=en. Accessed December 6, 2016.
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