New USPSTF Lipid Disorders Screening Recommendations 'Could Prove Controversial' Says One FP

The U.S. Preventive Services Task Force, or USPSTF, recently issued revised recommendations for screening for lipid disorders in adults. Although the USPSTF continues to strongly recommend screening all men ages 35 and older for lipid disorders and has not changed its stance on routine screening in men ages 20 to 35 (recommending neither for nor against), the guidance on screening women for these disorders has changed since the task force released its 2001 recommendations.

Specifically, the revised recommendation says "adult women at any age should be screened only if other risk factors for cardiovascular disease are present." The earlier version had recommended screening for younger women (ages 20-45) at increased risk for coronary heart disease, or CHD, and for all women older than 45.

Thomas Koinis, M.D., of Oxford, N.C., a member of the AAFP Commission on Science, said that he was surprised the USPSTF did not recommend screening women who aren't at increased risk for CHD, especially as they age. He said he thinks this USPSTF stance could prove controversial and added that he will be "interested in what women's groups or the American College of Obstetricians and Gynecologists have to say about it."

In addition, in the evidence synthesis update that accompanies the new recommendation statement, the USPSTF advises that if the results of an initial screening panel indicate a patient is at high risk of developing CHD, a second panel that includes measurement of triglyceride levels be administered. This recommendation contrasts with the NIH's National Cholesterol Education Program Adult Treatment Panel III, or ATP III, guidelines released in 2002. Those guidelines state that the initial screening lipid panel should include a triglyceride level.

The reason for this discrepancy? According to the USPSTF, "Results of recent studies are consistent with previous evidence and suggest that, although triglyceride level is a strong univariate predictor of CHD events, its association with such events is reduced substantially by adjustment for other risk factors."

Both the USPSTF and ATP-III recommend basing therapy on the average of two tests.

In practice, Koinis said, most FPs probably don't use two tests. They're more likely, he noted, to base their assessment of the patient's overall CHD risk on that initial test plus the presence or absence of various other risk factors, such as:

When estimating CHD risk, the ATP III guidelines define four levels of risk: presence of CHD or CHD equivalents; two or more risk factors and 10-year CHD risk of 10 percent to 20 percent; two or more risk factors and 10-year CHD risk less than 10 percent; and one or no risk factors and 10-year CHD risk of less than 10 percent. Lipid-lowering treatment goals are based on these risk levels.

The USPSTF does not define specific risk levels, although task force members do acknowledge that patients who have CHD risk equivalents may benefit from lipid-lowering therapy like that used in individuals who have known CHD. The task force also recognizes that some direct evidence shows that short-term primary prevention can be effective in high-risk individuals who have low LDL cholesterol levels, as well as in women with known coronary disease or diabetes.

The new USPSTF recommendations differ from the ATP III guidelines in other ways, as well, which Koinis said could lead to some confusion among family physicians regarding which guidelines they should follow in all instances. But perhaps help is on the way: The Academy's Commission on Science has not yet reviewed the revised USPSTF lipid screening recommendations but expects to do so soon.