On Dec. 21, the U.S. Preventive Services Task Force (USPSTF) posted two draft recommendation statements: one on statin use for primary prevention of cardiovascular disease (CVD) events in at-risk adults(www.uspreventiveservicestaskforce.org) and another on screening for lipid disorders in children and adolescents.(www.uspreventiveservicestaskforce.org)
The USPSTF recommends that people at increased risk for CVD (i.e., those with dyslipidemia, diabetes or hypertension and those who smoke) use statins to prevent CVD events (myocardial infarction or thrombotic stroke). This is a "B" recommendation(www.uspreventiveservicestaskforce.org) and applies to people without a history of CVD, symptomatic coronary artery disease or thrombotic stroke.
Evidence task force members reviewed showed that patients most likely to benefit from statin use are those ages 40-75 who have a risk factor for CVD and a calculated 10-year risk of having a CVD event of 10 percent or greater.
Patients ages 40-75 who have a risk factor for CVD but only a 7.5 percent to 10 percent calculated 10-year risk for a CVD event are less likely to benefit from statin use, and physicians should discuss treatment options with them individually. This is a "C" recommendation.
- The U.S. Preventive Services Task Force recommends that patients ages 40-75 who are at increased risk for cardiovascular disease (CVD) use statins to prevent CVD events.
- Patients with a 7.5 percent to 10 percent calculated 10-year risk are less likely to benefit from statin use, and physicians should discuss treatment options with them individually.
- In a separate recommendation, the task force found current evidence insufficient to assess the balance of benefits and harms of cholesterol screening in children and adolescents younger than age 20.
For patients age 76 or older who have no history of heart attack or stroke, the task force concluded that current evidence is insufficient to assess the balance of benefits and harms of statin use to prevent CVD events -- an "I" recommendation.
"People with no signs, symptoms or history of cardiovascular disease can still be at risk for having a heart attack or stroke," said USPSTF member Douglas Owens, M.D., M.S., in a news release.(www.uspreventiveservicestaskforce.org) "Fortunately, for certain people at increased risk, statins can be very effective at preventing these events."
In a separate recommendation, the task force found current evidence insufficient to assess the balance of benefits and harms of cholesterol screening in children and adolescents younger than age 20 -- an "I" recommendation.
Update on Statins to Prevent CVD Events
The draft recommendation statement on statin use to prevent CVD events replaces the USPSTF's 2008 recommendations on screening for lipid disorders in adults. The AAFP also released its own recommendations in 2008 on screening adults for lipid disorders.
The task force commissioned two systematic evidence reviews to update its 2008 recommendation that addressed
- the benefits and harms of screening for and treating dyslipidemia in asymptomatic adults ages 21-29, especially on CVD-related morbidity and mortality;
- the benefits and harms of statin use in reducing the incidence of CVD-related morbidity and mortality or all-cause mortality in asymptomatic adults without a history of CVD events;
- how the benefits of statin use vary by subgroup, clinical characteristics and potency; and
- the benefits of treatment-to-target versus other treatment strategies in asymptomatic adults ages 40 and older without a history of CVD events.
Eighteen randomized controlled trials evaluated the effects of statins versus placebo or no statin in adults ages 40-75 without known CVD. Most of the trials enrolled participants based on their elevated LDL cholesterol level or diabetes diagnosis.
The USPSTF recommends using the American College of Cardiology/American Heart Association (ACC/AHA) pooled cohort equations(my.americanheart.org) to calculate patients' 10-year risk of CVD events. However, said task force members, it's important to note that the predicted 10-year risk of CVD events derived using the ACC/AHA risk calculator is heavily influenced by age. "For example, 41 percent of men and 27 percent of women ages 60-69 without a history of CVD will be found to have a 10 percent or greater calculated 10-year risk of a CVD event," the draft recommendation noted.
Family physicians can help patients reduce their CVD risk by recommending they not smoke, eat a healthy diet, engage in physical activity and limit alcohol use. The USPSTF also said it's important for patients to manage their high blood pressure and high cholesterol and take aspirin when indicated to help prevent heart attacks and strokes.
Screening for Lipid Disorders
In a second draft recommendation statement, the USPSTF seeks to update its 2007 recommendation on whether screening for lipid disorders in children and adolescents (i.e., those younger than 20) leads to a lower risk of CVD events in adulthood. It found there wasn't enough evidence to assess the balance of benefits and harms of screening in this age group, and the recommendation remained unchanged from its previous "I" version. The AAFP released a similar recommendation in 2007.
"There is currently not enough research to determine whether screening all average-risk children and adolescents without symptoms leads to better cardiovascular health in adulthood," said task force Vice Chair David Grossman, M.D., M.P.H., in a news release.(www.uspreventiveservicestaskforce.org) "In addition, the potential harms of long-term use of cholesterol-lowering medication by children and adolescents are not yet understood."
To update its 2007 recommendation, the USPSTF commissioned two systematic evidence reviews on screening for lipid disorders in these patients. Based on public comment on the draft research plan, the task force also conducted two additional evidence reviews: one on screening for heterozygous familial hypercholesterolemia and the other on screening for multifactorial dyslipidemia.
Homozygous familial hypercholesterolemia and secondary causes of dyslipidemia (e.g., diabetes, nephrotic syndrome or hypothyroidism) were outside the scope of review.
Family physicians can help these young patients avoid high cholesterol by recommending they eat a healthy diet, maintain a normal weight and engage in physical activity.
The USPSTF will accept comments on the draft recommendation statement(www.uspreventiveservicestaskforce.org) regarding statin use to prevent CVD events and its accompanying draft evidence review(www.uspreventiveservicestaskforce.org) through Jan. 25.
The task force also will accept comments on the draft recommendation statement(www.uspreventiveservicestaskforce.org) regarding lipid disorder screening in children and adolescents and its accompanying draft evidence reviews on familial hypercholesterolemia(www.uspreventiveservicestaskforce.org) and on multifactorial dyslipidemia(www.uspreventiveservicestaskforce.org) through Jan. 25.
The AAFP is reviewing the USPSTF's draft recommendations and will update its own recommendation after the task force publishes its final recommendation statement.
Jennifer Frost, M.D., medical director for the AAFP Health of the Public and Science Division, pointed out to AAFP News that in 2014, the Academy endorsed (with qualifications) an ACC/AHA clinical practice guideline on statin therapy that used a CVD risk assessment tool with a 7.5 percent risk cutoff, in contrast to the USPSTF's recommended 10 percent risk cutoff. The AAFP specifically noted in its qualified endorsement that the lower risk cutoff would significantly increase the number of individuals on statins.
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