Original Article: Key Recommendations on Managing Dyslipidemia for Cardiovascular Risk Reduction: Stopping Where the Evidence Does [Editorial]
Issue Date: April 15, 2021
Available at: https://www.aafp.org/afp/2021/0415/p455.html
To the Editor: I was surprised that Dr. Arnold's editorial on the prevention of cardiovascular disease referenced only the American College of Cardiology and U.S. Department of Veterans Affairs and Department of Defense (VA/DoD) guidelines and did not mention the U.S. Preventive Services Task Force (USPSTF) recommendations.1 Many family physicians consider the USPSTF recommendations to be the “gold standard” and view other guidelines with skepticism because they may be beholden to commercial interests. The USPSTF guidelines are transparent because they show the evidence tables that were the basis for their recommendations. I was disappointed that the editorial did not specify the evidence base for the VA/DoD recommendations. I (and many other family physicians) will continue to follow the USPSTF recommendations.
In Reply: We thank Dr. Millard for their interest in trustworthy, conflict of interest–free guidelines. We chose not to include the USPSTF recommendations as a comparison to the VA/DoD guidelines because they are limited to primary prevention and are undergoing revision.1
The USPSTF is a volunteer group of multidisciplinary experts without conflicts of interest who commission systematic reviews to create guidelines focused on advancing the health of all Americans.2 The VA/DoD working groups are also volunteers, multidisciplinary, without conflicts of interest, and they commission independent systematic reviews for their guidelines.3 Although VA/DoD guidelines focus on the care of veterans, active duty service members, and their families, the USPSTF and VA/DoD adhere to the National Academy of Sciences tenets for trustworthy clinical guidelines.2,4
The primary prevention recommendations from the USPSTF and VA/DoD are similar. The USPSTF recommends low- to moderate-dose statins in adults 40 to 75 years of age who have a risk factor for cardiovascular disease and a 10-year atherosclerotic cardiovascular disease (ASCVD) risk of 10% or greater.5 The VA/DoD recommends moderate-dose statins in adults 40 to 75 years of age who have diabetes mellitus, low-density lipoprotein levels of 190 mg per dL (4.92 mmol per L) or greater, or a 10-year ASCVD risk score of 12% or greater, with shared decision-making recommended for those with ASCVD risk between 6% and 12%.4 Noting that there is not an ASCVD threshold where cardiac risk changes abruptly, the USPSTF states that “…any cut point for assessing where the net benefit of statin use shifts from small to moderate for a population requires judgment.”5 The VA/DoD guidelines note the same ambiguity. The USPSTF requires the presence of a cardiovascular risk factor and a threshold risk score because trials include risk factors. The VA/DoD chose a simpler, conservative threshold from interpreting clinical trial data.4,5 The USPSTF chose to make no recommendation for individuals with a low-density lipoprotein level greater than 190 mg per dL, whereas the VA/DoD recommends statin treatment for these individuals.4,5 Similar to the USPSTF, the VA/DoD guidelines transparently explain the rationale for each recommendation and include evidence tables.4
By addressing more common clinical situations than the USPSTF, the VA/DoD guideline offers straightforward guidance to treat patients we encounter regularly. Canadian Family Physician recognized the VA/DoD dyslipidemia guidelines as one of the “Top 2020 studies relevant to primary care”.6 For questions about ASCVD prevention outside of the USPSTF guidance, we hope that the VA/DoD guidelines can be helpful.
Editor's Note: Dr. Arnold is a contributing editor for AFP.
The views expressed in this article are those of the authors and do not reflect the position of the Department of the Navy, Uniformed Services University of the Health Sciences, Department of Defense, Department of Veterans Affairs, or the U.S. government.