correspondence
The New Cholesterol Treatment Guidelines To the Editor: Keaney et al. (Jan. 16 issue)1 succinctly summarize part of the 2013 guidelines of the American College of Cardiology–American Heart Association (ACC-AHA) for the treatment of high blood cholesterol levels.2 Unfortunately, the authors omitted the three key recommendations that make these guidelines truly pragmatic. First, assessment of the 10-year risk of atherosclerotic cardiovascular disease is only the starting point. A clinician and patient must discuss the potential for benefit with respect to reduction of this risk, adverse effects, and patient preferences before initiating the use of a statin for primary prevention. Second, moderate-intensity statin therapy may be initiated when the 10-year risk of atherosclerotic cardiovascular disease is 5.0 to less than 7.5%. And third, when a risk-based decision is uncertain, additional factors that may increase the risk of atherosclerotic cardiovascular disease can be considered. If these three key recommendations are ignored, the recommendations by Keaney et al. differ from the guidelines. The objective of the guideline panel, of which one of us was the chair and two of us were vicechairs, was to recommend statin therapy for patients who are most likely to benefit and to identify those who are less likely to benefit. We emphasize that guidelines can inform clinical judgment but do not replace it, especially in primary prevention. Neil J. Stone, M.D. Northwestern University Chicago, IL
Jennifer G. Robinson, M.D., M.P.H. University of Iowa Iowa City, IA
Alice Lichtenstein, D.Sc. Tufts University Boston, MA Dr. Robinson reports receiving grant support through her institution from Amarin, Amgen, AstraZeneca, Daiichi Sankyo, Esperion, Merck, Genentech/Hoffmann–La Roche, Pfizer, Regeneron, and Sanofi-Aventis, and consulting fees from Amgen, Pfizer, Regeneron, and Sanofi-Aventis. No other potential conflict of interest relevant to this letter was reported. 1. Keaney JF Jr, Curfman GD, Jarcho JA. A pragmatic view of
the new cholesterol treatment guidelines. N Engl J Med 2014;370: 275-8.
2. Stone N, Robinson J, Lichtenstein A, et al. 2013 ACC/AHA
Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2013 November 12 (Epub ahead of print).
DOI: 10.1056/NEJMc1403438
The Authors Reply: Stone et al. correctly point out that we did not provide a comprehensive discussion of the details in the current ACC-AHA cholesterol treatment guidelines regarding the initiation of statin therapy in persons without clinical atherosclerotic cardiovascular disease. We agree that practitioners should discuss with their patients the risks and benefits of statin therapy for primary prevention of atherosclerotic cardiovascular disease and should take into account patient preferences. In fact, one might submit that a risk–benefit discussion between clinicians and patients must take place before initiating any drug, for any medical problem. We also agree that when the risk of atherosclerotic cardiovascular disease is uncertain, clinicians should consider other tools such as biomarkers or imaging studies to delineate risk. Finally, we regret not including in our summary the option of moderateintensity statin therapy for patients with a 10-year risk of atherosclerotic cardiovascular disease of 5.0 to less than 7.5%. Risk-assessment tools such as the ACC-AHA risk calculator are not precise with respect to individual patients. Therefore, it is reasonable to consider moderate-intensity treatment when an assessment of a patient’s 10-year risk of atherosclerotic cardiovascular disease approaches 7.5%, as recommended in the guidelines. John F. Keaney, Jr., M.D. University of Massachusetts Medical School Worcester, MA
Gregory D. Curfman, M.D. John A. Jarcho, M.D. Since publication of their article, the authors report no further potential conflict of interest. DOI: 10.1056/NEJMc1403438
n engl j med 370;20 nejm.org may 15, 2014
The New England Journal of Medicine Downloaded from nejm.org at SUNY HSC BROOKLYN on April 11, 2015. For personal use only. No other uses without permission. Copyright © 2014 Massachusetts Medical Society. All rights reserved.
1957
The New Cholesterol Treatment Guidelines To the Editor: Keaney et al. (Jan. 16 issue)1 succinctly summarize part of the 2013 guidelines of the American College of Cardiology–American Heart Association (ACC-AHA) for the treatment of high blood cholesterol levels.2 Unfortunately, the authors omitted the three key recommendations that make these guidelines truly pragmatic. First, assessment of the 10-year risk of atherosclerotic cardiovascular disease is only the starting point. A clinician and patient must discuss the potential for benefit with respect to reduction of this risk, adverse effects, and patient preferences before initiating the use of a statin for primary prevention. Second, moderate-intensity statin therapy may be initiated when the 10-year risk of atherosclerotic cardiovascular disease is 5.0 to less than 7.5%. And third, when a risk-based decision is uncertain, additional factors that may increase the risk of atherosclerotic cardiovascular disease can be considered. If these three key recommendations are ignored, the recommendations by Keaney et al. differ from the guidelines. The objective of the guideline panel, of which one of us was the chair and two of us were vicechairs, was to recommend statin therapy for patients who are most likely to benefit and to identify those who are less likely to benefit. We emphasize that guidelines can inform clinical judgment but do not replace it, especially in primary prevention. Neil J. Stone, M.D. Northwestern University Chicago, IL
Jennifer G. Robinson, M.D., M.P.H. University of Iowa Iowa City, IA
Alice Lichtenstein, D.Sc. Tufts University Boston, MA Dr. Robinson reports receiving grant support through her institution from Amarin, Amgen, AstraZeneca, Daiichi Sankyo, Esperion, Merck, Genentech/Hoffmann–La Roche, Pfizer, Regeneron, and Sanofi-Aventis, and consulting fees from Amgen, Pfizer, Regeneron, and Sanofi-Aventis. No other potential conflict of interest relevant to this letter was reported. 1. Keaney JF Jr, Curfman GD, Jarcho JA. A pragmatic view of
the new cholesterol treatment guidelines. N Engl J Med 2014;370: 275-8.
2. Stone N, Robinson J, Lichtenstein A, et al. 2013 ACC/AHA
Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2013 November 12 (Epub ahead of print).
DOI: 10.1056/NEJMc1403438
The Authors Reply: Stone et al. correctly point out that we did not provide a comprehensive discussion of the details in the current ACC-AHA cholesterol treatment guidelines regarding the initiation of statin therapy in persons without clinical atherosclerotic cardiovascular disease. We agree that practitioners should discuss with their patients the risks and benefits of statin therapy for primary prevention of atherosclerotic cardiovascular disease and should take into account patient preferences. In fact, one might submit that a risk–benefit discussion between clinicians and patients must take place before initiating any drug, for any medical problem. We also agree that when the risk of atherosclerotic cardiovascular disease is uncertain, clinicians should consider other tools such as biomarkers or imaging studies to delineate risk. Finally, we regret not including in our summary the option of moderateintensity statin therapy for patients with a 10-year risk of atherosclerotic cardiovascular disease of 5.0 to less than 7.5%. Risk-assessment tools such as the ACC-AHA risk calculator are not precise with respect to individual patients. Therefore, it is reasonable to consider moderate-intensity treatment when an assessment of a patient’s 10-year risk of atherosclerotic cardiovascular disease approaches 7.5%, as recommended in the guidelines. John F. Keaney, Jr., M.D. University of Massachusetts Medical School Worcester, MA
Gregory D. Curfman, M.D. John A. Jarcho, M.D. Since publication of their article, the authors report no further potential conflict of interest. DOI: 10.1056/NEJMc1403438
n engl j med 370;20 nejm.org may 15, 2014
The New England Journal of Medicine Downloaded from nejm.org at SUNY HSC BROOKLYN on April 11, 2015. For personal use only. No other uses without permission. Copyright © 2014 Massachusetts Medical Society. All rights reserved.
1957
