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Th e new england journal o f medicine Application of New Cholesterol Guidelines to a Population-Based Sample

Michael J. Pencina, Ph.D., Ann Marie Navar-Boggan, M.D., Ph.D.,Ralph B. DAgostino, Sr., Ph.D., Ken Williams, M.S., Benjamin Neely, M.S.,

Lela mantiliPresly siharOri aprisia putriTh e new england journal o f medicine 2014Application of New Cholesterol Guidelinesto a Population-Based SampleBackground The 2013 guidelines of the American College of Cardiology and the American Heart Association (ACCAHA) for the treatment of cholesterol expand the indications for statin therapy for the prevention of cardiovascular disease.Methods Sample data colected between 2005-2010 using data from the national health and nutrition examination survey (NHANES)3909 Participant (ages : 40-75 years)->3773Exlude : 100 participant who had triglyceride level of more than 400 mg/deciliter and 36 participant who had missing data with respect to LDL cholesterolAssesed the eligibility for therapy statin-> ATP III CRITERIA & 2013 ACC-AHA GUIDLINESStatistical analysis 3773 participants in the NHANES sample for whom statin therapy would be recommended (i.e., eligible persons) on the basis of the two sets of guidelines.We then used domain analysis to extrapolate the results in our sample of 3773 participants to the population of 115.4 million U.S. adults between the ages of 40 and 75 years who have triglyceride levels below 400 mg per deciliter.Statistical analysis All analyses were performed with use of SAS software, version 9.3Results

Study sample

Extrapolation of Results to U.S. Population

The estimated numbers ofadults who would be eligible for statin therapyaccording to each of the individual criteria in theATP-III guidelines and the new ACCAHA guidelines.

Given the differences in the guideline recommendationsfor primary preventionAmong adults between the ages of 40 and 59 years, the proportions of those who would be eligible for treatment are similar(27.0% according to the ATP-III guidelines and 29.7% according to the ACCAHA guidelines).

However, we found a substantial difference in eligibility between the two sets of guidelines among older adults between the ages of 60 and 75 years. In this age group, 47.8% of adults wouldbe receiving or be eligible for statin therapy according to the ATP-III guidelines as comparedwith 77.3% according to the ACCAHA guidelines.Discordance between the Two Sets of Guidelines

DiscussionThe new ACCAHA cholesterol guidelines differ substantially from the previous ATP-III guidelines, particularly with respect to primary prevention of cardiovascular diseaseACCAHA cholesterol guidelines VS ATP-III guidelines More emphasis on levels of LDLcholesterol to select patients for statin therapysolely on the 10-year predicted risk, as long as the LDL cholesterol level is 70 mg perdeciliter or higherUsing NHANES data, we estimated the effects of these changes on the percentage and mix of the U.S. population for whom statin therapy would be recommendedThis population would represent a net increase of 12.8 million potential new statin users (an increase of 11.1 percentage points) over the number who would be eligible according to the ATP-III guidelines. * Further research is required to determine whether more aggressive preventive strategies are needed for younger adults.These new treatment recommendations have a larger effect in the older age group (60 to 75 years) than in the younger age group (40 to 59 years)Although up to 30% of adults in the younger age group without cardiovascular disease would be eligible for statin therapy for primary prevention, more than 77% of those in the older age group would be eligibleThis difference might be partially explained by the addition of stroke to coronary heart disease as a target for prevention in the new pooled-cohort equations.Since the prevalence of cardiovascular disease rises markedly with age,11 the large proportions of older adults who would be eligible for statin therapy may be justifiableAs compared with the ATP-III guidelines The new guideline recommendations would also result in more men being newly eligible for statin therapy than womenAlthough the overall percentages of the two sexes that would be eligible for therapy would remain similarThe new guidelines would also expand the eligibility for statin therapy among adults with a higher blood pressure but substantially lower levels of LDL cholesterol14Assuming that the 10-year general cardiovascular risk estimates of DAgostino et al., when applied to our NHANES sample, would accurately reflect future event rates for the U.S. population, we projected that there will be 11.4 million new cases of cardiovascular disease over the next 10 years among the 103.5 million adults between the ages of 40 and 75 years who do not currently have cardiovascular disease. We also attempted to estimate the likely effect of the full adoption of the new guidelines on future rates of cardiovascular events.Using these calculations,we estimatedbut not according to the ATP-III guidelines, a difference of 1.9 millionthat 16.8% of these 11.4 million adults would be eligible for statin therapy according to the new guidelinesIf statin therapy then reduces the relative cardiovascularrisk by 25%, as suggested in metaanalysesof statin use in primary prevention,12 atotal of approximately 475,000 future cardiovascularevents would be prevented. More than 90%of this potential benefit would occur amongolder adults

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