In November 2016 the influential U.S. Preventive Services Task Force released recommendations about the use of cholesterol-lowering statin drugs in people without known cardiovascular disease (CVD). These are similar to still-debated guidelines issued by the American College of Cardiology and American Heart Association (ACC/AHA) in 2013 in that they set aside the specific numeric targets for cholesterol levels that were the basis of the National Cholesterol Education Program for the previous quarter century. They focus instead on treating people who are at elevated risk for CVD, regardless of their cholesterol numbers, and are thus most likely to benefit from treatment. But there are some important differences, notably that the Task Force guidelines are likely to advise statins for fewer people.
- The Task Force recommends statins for people ages 40 to 75 who have at least one CVD risk factor—such as high LDL (“bad”) cholesterol, low HDL (“good”) cholesterol, diabetes, hypertension, or smoking—plus a 10-year risk of CVD of at least 10 percent. The latter is determined by the same risk assessment tool used by ACC/AHA. In contrast, the ACC/AHA guidelines set a lower cutoff for the risk calculator, 7.5 percent, and do not require a separate CVD risk factor like smoking or hypertension, so they produce more candidates for statins.
- The Task Force recommends that health care providers selectively offer statins to adults ages 40 to 75 years who have at least one CVD risk factor and a 10-year risk between 7.5 and 10 percent. The ACC/AHA guidelines set these cutoffs lower, between 5 and 7.5 percent.
- Like ACC/AHA, the Task Force has no recommendation about starting statin therapy in people over 75 with no history of CVD because there is insufficient evidence to assess the balance of benefits and harms for them. This does not include older people who started statins before age 75, most of whom presumably can continue taking them past that age. Since data are also lacking for the efficacy of screening and treating adults ages 20 to 39, health care providers should “use their clinical judgment” for them as well.
The Task Force’s recommendations, like previous guidelines, were criticized by some experts for being too aggressive, and by others for not being aggressive enough.
We are hesitant to endorse these new guidelines, just as we hesitated about the ACC/AHA ones. It’s not clear that they will be more effective than the old target-based recommendations—or those from ACC/AHA. But don’t let the endless debate about details of the various guidelines deter you from getting a cholesterol screening and CVD risk evaluation. Most people who would be prescribed statins under the new guidelines would have been prescribed them under previous ones as well. In cases that are less clear, “clinician knowledge, experience, and skill (‘the art of medicine’), and patient preferences, all contribute to the decision to initiate statin therapy,” as the ACC/AHA guidelines state.
Shared decision-making: It’s essential to talk with your health care provider about your CVD risk factors and how you can modify them (via diet, exercise, and weight control) as well as the potential benefits and risks of statins, if you’re a candidate for one. It may be helpful for you and your provider to use an online “decision aid."