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Lipid levels decreased since publication of 2013 cholesterol guidelines
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Lipid and lipoprotein levels have declined since the 2013 American College of Cardiology/American Heart Association cholesterol guidelines were published, according to a study published in the Journal of the American College of Cardiology.
Despite this benefit, awareness of high cholesterol levels among patients who were eligible for statin therapy has remained stable, according to the study.
“The declining lipid and lipoproteins levels, as outlined in the current study, may be explained by the relative increase in the proportion of U.S. adults taking lipid-lowering medications over the course of the study period,” Nirav Patel, MD, resident in the division of cardiovascular disease at University of Alabama at Birmingham, and colleagues wrote. “Additionally, in those not on lipid-lowering therapies, the favorable trends in lipid profiles may be due to a decrease in consumption of trans-fatty acids or other nonhealthy lifestyles such as physical inactivity and smoking.”
Researchers analyzed data from 32,278 patients from 2005-2006 and 2015-2016 National Health and Nutrition Examination Survey to assess trends in lipid and lipoprotein levels in adults before and after the guidelines were published.
Among patients taking lipid-lowering medication, mean total cholesterol declined from 206 mg/dL in 2005-2006 (95% CI, 198-215) to 191 mg/dL in 2013-2014 (95% CI, 184-198). An additional decline was also seen from 2013-2014 to 2015-2016 (191 mg/dL to 187 mg/dL).
Mean LDL decreased from 122 mg/dL (95% CI, 113-130) to 107 mg/dL (95% CI, 98-116) during the two periods among patients taking lipid-lowering medications. This also declined from 107 mg/dL in 2013-2014 to 101 mg/dL in 2015-2016. HDL did not change during the two periods.
The proportion of patients who were eligible for statin therapy and were told they had high cholesterol increased from 2005-2016 to 2011-2012 (63.6% to 69.4%), but remained unchanged from 2011-2012 through 2015-2016 (P for trend = .14). The percentage of patients taking a statin increased from 41.3% in 2005-2006 (95% CI, 37.5-45.2) to 49.2% in 2015-2016 (95% CI, 45.7-52.6).
The proportion of patients with clinical atherosclerotic CVD who were made aware of their high cholesterol levels increased from 2005-2006 to 2015-2016 (51.5% to 67.7%; P for linear trend = .07). This did not change among adults with an ASCVD risk of at least 7.5%.
“Previous studies showed that health care providers might not fully understand the guidelines,” Patel and colleagues wrote. “This could explain the plateauing of awareness. Improving patients’ perception of statin safety by alleviating fears of side effects and educational intervention targeting gaps at the patient as well as health care provider level may improve the dissemination of the 2013 ACC/AHA cholesterol guidelines.” – by Darlene Dobkowski
Disclosures: Patel reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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Neil J. Stone, MD
This is an important study. It uses NHANES data to tell us about the level of awareness of cholesterol and statin use from 2006 to 2017, and particularly to tell us about statin use before and after the 2013 AHA/ACC guidelines (Stone NJ, et al. Circulation. 2013;doi:10.1161/01.cir.0000437738.63853.7a).
Those guidelines were important because they changed the paradigm from treating based on fixed lipid targets (for which there were no clinical trial data to support the exact number) to first talking about risk. This current paper on trends in lipids and statin use shows that clinicians appear to be thinking about atherosclerotic CVD risk.
Two findings are very important in that regard. First, a group at high longer-term risk such as patients with diabetes aged 40 to 75 years are shown to have an increase in statin treatment in this paper. That’s very important because when a patient with diabetes develops an acute MI, they’re at much higher risk for complications or untoward outcomes after that MI than are those who do not have diabetes.
Second, the data support the notion that perhaps clinicians were listening to the 2013 guidelines that said if you have a greater than 7.5% 10-year risk, you don’t automatically get a statin, but you should first have a risk-benefit discussion with shared decision making before the statin prescription was written. The 2013 ACC/AHA cholesterol guideline was one of the first guidelines to talk about that, and it was an important part of the guideline. It looks like that clinicians probably did listen somewhat, as there was a significant change in statin use with diabetes for those aged 40 to 75 years as noted above, but although there was statin use, clearly not everybody who had over 7.5% 10-year risk was prescribed a statin. The hope is that there was more involvement of the patient in that risk-benefit decision.
This study adds useful insights and I would point out that the clinician-patient risk discussion has been greatly improved by the 2018 AHA/ACC multi-society guidelines (Grundy SM, et al. J Am Coll Cardiol. 2018;doi:10.1016/j.jacc.2018.11.003) that were presented last year at this time.
This paper corroborates what our aim was, that is, to focus on atherosclerotic CVD risk first and then the LDL level instead of just treating the LDL levels with fixed targets.
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