Atherosclerotic Cardiovascular Disease Prevention
2014; Lippincott Williams & Wilkins; Volume: 7; Issue: 5 Linguagem: Inglês
10.1161/circoutcomes.114.001139
ISSN1941-7705
AutoresAndré Paixão, Colby Ayers, Jarett D. Berry, James A. de Lemos, Amit Khera,
Tópico(s)Diabetes, Cardiovascular Risks, and Lipoproteins
ResumoHomeCirculation: Cardiovascular Quality and OutcomesVol. 7, No. 5Atherosclerotic Cardiovascular Disease Prevention Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBAtherosclerotic Cardiovascular Disease PreventionA Comparison Between the Third Adult Treatment Panel and the New 2013 Treatment of Blood Cholesterol Guidelines Andre R.M. Paixao, MD, Colby R. Ayers, MS, Jarett D. Berry, MD, MS, James A. de Lemos, MD and Amit Khera, MD, MSc Andre R.M. PaixaoAndre R.M. Paixao From the Division of Cardiology (A.R.M.P., J.D.B., J.A.d.L., A.K.) and Department of Clinical Sciences (C.R.A., J.D.B.) at the University of Texas Southwestern Medical Center, Dallas. , Colby R. AyersColby R. Ayers From the Division of Cardiology (A.R.M.P., J.D.B., J.A.d.L., A.K.) and Department of Clinical Sciences (C.R.A., J.D.B.) at the University of Texas Southwestern Medical Center, Dallas. , Jarett D. BerryJarett D. Berry From the Division of Cardiology (A.R.M.P., J.D.B., J.A.d.L., A.K.) and Department of Clinical Sciences (C.R.A., J.D.B.) at the University of Texas Southwestern Medical Center, Dallas. , James A. de LemosJames A. de Lemos From the Division of Cardiology (A.R.M.P., J.D.B., J.A.d.L., A.K.) and Department of Clinical Sciences (C.R.A., J.D.B.) at the University of Texas Southwestern Medical Center, Dallas. and Amit KheraAmit Khera From the Division of Cardiology (A.R.M.P., J.D.B., J.A.d.L., A.K.) and Department of Clinical Sciences (C.R.A., J.D.B.) at the University of Texas Southwestern Medical Center, Dallas. Originally published5 Aug 2014https://doi.org/10.1161/CIRCOUTCOMES.114.001139Circulation: Cardiovascular Quality and Outcomes. 2014;7:778–779Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2014: Previous Version 1 IntroductionThe recently released American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines on the Treatment of Blood Cholesterol propose significant changes to current practice patterns.1 The adoption of these new guidelines in place of the National Cholesterol Education Program/Third Adult Treatment panel (ATPIII)2 recommendations has recently been estimated to result in an 11% increase in statin eligibility, representing 12.8 million Americans.3 Although the magnitude of change in statin eligibility has been a topic of focus, the impact of the new guidelines on atherosclerotic cardiovascular disease (ASCVD) event rates and efficiency of additional statin use cannot be determined from the studies published to date. Knowledge of ASCVD event rates among reclassified individuals is essential to fully understand the implications of adopting the ACC/AHA guidelines.We sought to assess the implications of applying this new paradigm in place of the ATPIII recommendations on ASCVD event reduction and efficiency of statin utilization.Methods and ResultsThe Dallas Heart Study is a multiethnic cohort of Dallas County residents, age 30 to 65 years, examined between 2000 and 2002 and actively followed for cardiovascular outcomes.4 All participants provided informed consent, and the study was approved by the Institutional Review Board of the University of Texas Southwestern Medical Center. Sampling weights were applied to generate unbiased estimates of population frequencies in Dallas County.4 The primary outcome of ASCVD was defined as coronary heart disease (CHD) death, myocardial infarction, and fatal and nonfatal stroke.1 Secondary analysis was performed for CHD events (ie, CHD death and myocardial infarction).2 Participants were classified as statin eligible or ineligible using (1) ATPIII recommendations including the Framingham Risk Score and low-density lipoprotein cholesterol levels and (2) ACC/AHA algorithm including the Pooled Cohort Equations (Table I in the Data Supplement).1,2 Similar to prior studies, individuals on statins at baseline were considered eligible by both guidelines.3 Reclassification of statin eligibility from ATPIII to the AHA/ACC guidelines was determined, and ASCVD event rates were assessed among newly statin-eligible individuals. Net reclassification improvement was calculated as previously described.5 Using the same framework applied in the ACC/AHA guidelines, the number of prevented ASCVD events was estimated based on the number of events that occurred among statin-eligible individuals and assuming a relative risk reduction of 30% to 35% for moderate-intensity statin therapy and 45% for high-intensity statin therapy.1 The number of statin-related excess cases of diabetes mellitus was estimated assuming 0.1 and 0.3 extra cases per 100 person-years for moderate- and high-intensity statin therapy, respectively.1 Analyses were performed comparing the ACC/AHA guidelines with both the standard and optional low-density lipoprotein cholesterol goals from ATPIII.2A total of 2848 participants were assessed for statin eligibility according to both guidelines. Over a mean follow-up of 9.1±1.3 years, 129 ASCVD events including 70 CHD events occurred. After the application of sample weights, the median age of the population was 43 years, 49.9% were women, 19.0% were black, 7.9% had diabetes mellitus, and 3.4% had prior ASCVD (Table II in the Data Supplement).Overall, 17.2% of individuals were classified as statin eligible by ATPIII and 22.0% by the ACC/AHA guidelines (net increase 4.8%, relative increase 27.9%). The ASCVD event rate among newly statin-eligible individuals was 15.8% with an estimated one ASCVD event prevented for each additional 14 patients treated with high-dose statins and 21 treated with moderate-dose statins (Table). The net increase in statin eligibility was 37.1% among participants with ASCVD events and 3.9% among participants without ASCVD events, resulting in a net reclassification improvement of 0.332 (P<0.001; Table III in the Data Supplement). Excluding individuals on statins at baseline resulted in a net 5.2% increase in statin eligibility with a 15.8% ASCVD event rate among the newly statin eligible and a similar number needed to treat. Results were also similar when the analysis was restricted to individuals ≥40 years old (Table; Table III in the Data Supplement).Table. Additional Statin Eligibility and ASCVD Event Rates Among Newly Statin Eligible IndividualsOutcomeAdditional Statin Eligibility*Event Rate Among Newly Statin EligibleNNT Among Newly Statin Eligible†Primary analysis ASCVD4.8%15.8%14–21 CHD4.8%11.7%19–29ATPIII statin eligibility determined by optional cholesterol goals ASCVD−2.8%15.7%14–21 CHD−2.8%12.4%18–27Restricting to individuals aged ≥40 years ASCVD9.0%15.8%14–21 CHD9.0%11.6%19–29ASCVD indicates atherosclerotic cardiovascular disease; ATPIII, Third Adult Treatment panel; CHD, coronary heart disease; and NNT, number needed to treat.*Additional statin eligibility is the net product of those newly statin eligible and those no longer statin eligible under the new guidelines.†Number needed to treat with moderate to high potency statin to prevent one atherosclerotic cardiovascular event assuming a 30% to 45% relative risk reduction.Applying the ACC/AHA guidelines in place of ATPIII would result in an additional 3.6 to 4.9 prevented ASCVD events for every 1000 individuals screened and accordingly treated with moderate- or high-dose statins, respectively, with 0.5 to 1.5 excess cases of diabetes mellitus (Figure I in the Data Supplement). When applied to the source population of Dallas County residents aged 30 to 65 (n=973 726), an additional 4479 to 4771 ASCVD events would be prevented.When the ACC/AHA guidelines were compared with the optional ATPIII low-density lipoprotein cholesterol goals,2 even though a net reduction of 2.8% in statin eligibility was observed, newly statin-eligible individuals had an ASCVD event rate and number need to treat which were comparable to the primary analysis (Table) and a net reclassification improvement of 0.199 (P<0.001; Table III in the Data Supplement). Restricting the outcome to CHD events yielded similar results (Table; Table III in the Data Supplement). Assuming a more conservative 25% ASCVD relative risk reduction for statin therapy,6 the number needed to treat to prevent one event among newly statin-eligible individuals would be 25 and 2.7. ASCVD events would be prevented for every 1000 individuals screened and accordingly treated.CommentThe release of the ACC/AHA guidelines was followed by a heated debate that was often centered on the expansion of statin eligibility. Our findings are consistent with a recent report from the National Health and Nutrition Examination Surveys and suggest that, among individuals <60 to 65 years, adopting the ACC/AHA guidelines would result in a modest absolute increase in statin eligibility.3 Beyond reporting on additional statin use, we apply actual event rates to show that in this age group, additional statin use with adoption of the new guidelines seems reasonably efficient and effective. Newly statin-eligible individuals had high ASCVD event rates (15.8%), resulting in an efficient number needed to treat (14–21) to prevent one ASCVD event. Over one third of individuals with ASCVD events were newly classified as statin eligible, and there was an acceptable balance between prevented ASCVD events and new-onset diabetes mellitus.The implications for practitioners who have adopted the ATPIII optional low-density lipoprotein cholesterol goals would be more modest as switching to the ACC/AHA recommendations would actually decrease statin eligibility by 2.8% among individuals in this age range. The new guidelines, however, resulted in a more efficient use of statins with a 15.7% event rate among the newly statin eligible, translating into a persistent but lesser reduction in ASCVD events (1.6–2.2 per 1000 screened).Our results from a contemporary, multiethnic, younger population suggest that the application of the ACC/AHA guidelines will have a favorable effect on ASCVD prevention with reasonable efficiency of statin use when compared with the prior ATPIII recommendations. The net effect of the new recommendations should also be assessed in older populations and in those with different ethnic composition.Sources of FundingThe Dallas Heart Study was funded by the Donald W. Reynolds Foundation (Las Vegas, NE) and partially supported by the National Center for Advancing Translational Sciences of the National Institutes of Health (Bethesda, MD) under award number UL1TR001105.DisclosuresDr de Lemos has received honoraria and consulting fees from Astra Zeneca and consulting fees from Sanofi/Regeneron and Amgen. Dr Berry is a member of the Speakers Bureau for Merk & Co. The other authors report no conflicts.FootnotesThe Data Supplement is available at http://circoutcomes.ahajournals.org/lookup/suppl/doi:10.1161/CIRCOUTCOMES.114.001139/-/DC1.Correspondence to Amit Khera, MD, MSc, Division of Cardiology, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390–8830. E-mail [email protected]References1. 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Zhao D, Liu J, Xie W and Qi Y (2015) Cardiovascular risk assessment: a global perspective, Nature Reviews Cardiology, 10.1038/nrcardio.2015.28, 12:5, (301-311), Online publication date: 1-May-2015. September 2014Vol 7, Issue 5 Advertisement Article InformationMetrics © 2014 American Heart Association, Inc.https://doi.org/10.1161/CIRCOUTCOMES.114.001139PMID: 25097213 Manuscript receivedMay 17, 2014Manuscript acceptedJune 25, 2014Originally publishedAugust 5, 2014 Keywordscardiovascular diseasescholesterolPDF download Advertisement SubjectsEpidemiologyPrimary PreventionSecondary Prevention
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