Estimating the Potential Effect of the New Cholesterol Guidelines

Summary and Comment |
March 25, 2014

Estimating the Potential Effect of the New Cholesterol Guidelines

  1. Allan S. Brett, MD

The 2013 American College of Cardiology and American Heart Association guidelines recommend statin therapy for most people who are 60 to 75.

  1. Allan S. Brett, MD

Anyone who has plugged numbers into the new risk calculator from the American College of Cardiology and American Heart Association (ACC-AHA) will recognize that more people — especially older adults without clinical evidence of cardiovascular (CV) disease — would be classified as “eligible” for statin therapy according to the new cholesterol guidelines (NEJM JW Gen Med Nov 12 2013). To quantitate this effect, researchers used data from a representative sample of 3800 adults (age range, 40–75) and extrapolated from this sample to the overall U.S. population.

Compared with the 2004 Third Adult Treatment Panel (ATP-III) guidelines, following the new ACC-AHA guidelines would increase the proportion of people 40 to 75 recommended for statin therapy from 38% to 49%. Primary preventive treatment of older adults without known CV disease would account for much of this increase: The proportion of 60- to 75-year-olds recommended for statin therapy would rise from 48% (according to ATP-III) to 77% (according to ACC-AHA). This difference reflects the fact that the new guidelines recommend treating people whose 10-year CV risk exceeds 7.5%, even when their LDL cholesterol levels are as low as 70 mg/dL. In contrast, higher LDL levels and higher 10-year risk generally were required for initiating statins under the old ATP-III guideline.


This analysis provides a reasonable estimate of potentially broader use of statins under the new cholesterol guidelines. Whether clinicians and patients will adhere closely to these recommendations remains to be seen. In particular, some clinicians still are cautious about prescribing statins for patients whose 10-year cardiovascular risk is near the 7.5% threshold, given reports that the new calculator might overestimate 10-year risk in some patients.

Editor Disclosures at Time of Publication

  • Disclosures for Allan S. Brett, MD at time of publication Nothing to disclose


Reader Comments (3)

bradley kays Physician, Internal Medicine, Newport Beach

These guidlines are over the top. I think in many cases it gives overly aggressive practitioners a license to prescribe medications and not worry about the adverse consequences of the drug. In this case an error of commission is better than one of omission. It takes more time and effort to NOT prescribe something. Same story with the FRAX calculators. Every female over 70 with an average DEXA needs a drug too. We see the same panel philosphy at work.


I offer any patient over 40 (though most over 50) a coronary calcium score study to determine if they really need to take a statin. These are mostly low and moderate risk patients. They must pay for the scan but it is offered at less than $150 in many locations. If their cholesterol profile is not too abnormal (I use non HDL cholesterol <130 for a cutoff), and their score is "0", I don't treat. If they have any score, or for patients with high risk (especially DM, bad family history), I treat regardless of their age, or levels. This incorporates parts of various papers which have been published in peer reviewed journals over the years. Am I making a mistake? To my knowledge with a 10 year history of using these criteria, I have not yet been "burned".

Dr. V Kantariya MD Physician, Family Medicine/General Practice

The new cholesterol guideline recommends a rule of thumb for comparing statin doses that lower LDL-C approximately 30% to 35%. When total CV risk favours statin treatment, but some statins are associated with Exess Risk for Diabetes. CHOOSING WISELY!

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