Applicability and potential clinical effects of 2013 cholesterol guidelines on major cardiovascular events

The applicability to different race/ethnic groups and effects on cardiovascular disease (CVD) outcomes of the 2013 American College of Cardiology and American Heart Association (ACC/AHA) guidelines for cholesterol management remain to be determined. We estimated the proportion of Korean adults who would be affected by the 2013 cholesterol guidelines and to determine the related effects on cardiovascular events.

Using data from the Korean National Health and Nutrition Examination Survey of 2008 to 2012 (n = 18,573), we compared the estimated number of statin candidates under the 2013 ACC/AHA and the Third Adult Treatment Panel (ATP-III) guidelines and extrapolated the results to 19.0 million Koreans between the ages of 40 and 75 years. Using an external cohort (n = 63,329) from the 2003 National Health Examination with 7 years of prospective follow-up, we determined the potential effects of recent recommendations changes on atherosclerotic CVD events (composite of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke).

Compared with the ATP-III guidelines, the ACC/AHA guidelines would increase the number of statin candidates from 3.5 million (18.6%) to 6.7 million (35.1%). The increase of statin candidates would be larger among older adults (60-75 years; from 29.8% to 74.9%) as compared with younger adults (40-59 years; from 15.6% to 19.8%) and among men (from 25.7% to 45.4%) compared with women (from 14.6% to 26.8%). In the external cohort, compared with adults who were recommended by neither of the 2 guidelines, those who were recommended by both and those who were recommended by ACC/AHA but not ATP-III guidelines had significantly higher risks of atherosclerotic CVD events (hazard ratios [HRs] 3.65 [95% CI, 3.33-4.02] and 3.98 [95% CI 3.64-4.35], respectively). However, adults who were recommended by ATP-III but not ACC/AHA guidelines did not have an increased risk (HR 0.90, 95% CI 0.64-1.28).

In the Korean population, the 2013 ACC/AHA cholesterol guidelines would substantially increase the number of adults who are potentially eligible for statin therapy and would recommend statin therapy for more adults at higher cardiovascular risk. However, the clinician-patient discussion of the potential benefits, possible harms, and other factors before the initiation of statin therapy must be considered.