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

Jerry C Lee, Tomasz Zdrojewski, Michael J Pencina, Adam Wyszomirski, Mateusz Lachacz, Grzegorz Opolski, Piotr Bandosz, Marcin Rutkowski, Zbigniew Gaciong, Bogdan Wyrzykowski, Ann M Navar
JAMA Cardiology 2016 September 1, 1 (6): 700-7

IMPORTANCE: The American College of Cardiology/American Heart Association (ACC/AHA) guidelines for the management of blood cholesterol and the 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 effect of the ACC/AHA and ESC/EAS cholesterol guidelines when applied to a population-based sample.

DESIGN, SETTING, AND PARTICIPANTS: We used nationally representative data for 3055 adults aged 40 to 65 years from the 2007-2012 National Health and Nutrition Examination Surveys (NHANES) for the United States and for 1060 adults aged 40 to 65 years from the 2011 Nadciśnięnie Tętnicze w Polsce survey for Poland. Data analysis was conducted from May 1, 2014, to December 31, 2015.

MAIN OUTCOMES AND MEASURES: The number and characteristics of adults recommended for statin therapy according to the ACC/AHA and ESC/EAS guidelines were evaluated, and characteristics were compared between adults with discordant recommendations.

RESULTS: The 3136 US adults in NHANES (2007-2012) aged 40 to 65 years represented 100.1 million adults; after excluding the 81 patients with missing data, these population estimates translate to 97.9 million adults. Similarly, the 1060 Polish adults in NATPOL (2011) aged 40 to 65 years represent 13.5 million adults. Using weighted data, in the United States, 43.8% (95% CI, 40.9%-46.7%) of adults would be recommended for statin therapy according to ACC/AHA guidelines and 39.1% (95% CI, 36.4%-41.8%) according to ESC/EAS guidelines. In Poland, 49.9% (95% CI, 46.9%-52.9%) of adults would be recommended for statin therapy under ACC/AHA guidelines compared with 47.6% (95% CI, 44.6%-50.7%) under ESC/EAS guidelines. Among individuals without cardiovascular disease and not currently taking statins, 11.0% of US and 10.5% of Polish adults had discordant guideline recommendations. Compared with individuals recommended for statin therapy by the ESC/EAS guidelines but not the ACC/AHA guidelines, those recommended for statin therapy under the ACC/AHA guidelines only had less chronic kidney disease; however, these individuals were also more likely to smoke, have lower high-density lipoprotein cholesterol levels, and have higher predicted 10-year risk of cardiovascular disease.

CONCLUSIONS AND RELEVANCE: 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. Discordant recommendations were driven by differences in the risk equations used in the 2 guidelines and different recommendations for adults with chronic kidney disease.

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