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Coronary risk estimation and treatment of hypercholesterolemia
A Simon1, J L Megnien, J Levenson
1Centre de Médecine Préventive Cardiovasculaire, CR Inserm, Hôpital Broussais, Paris, France.
Insights
Current hypercholesterolemia treatment guidelines use risk estimates, but discrepancies exist. Further studies are needed to refine patient selection for lipid-lowering therapy based on coronary risk profiles.
Area of Science:
- Cardiology
- Pharmacology
- Preventive Medicine
Background:
- Evidence-based hypercholesterolemia treatment relies on randomized trials (e.g., WOSCOPS, 4S) and patient coronary risk assessment.
- Current guidelines aim to rationalize drug prescription for high cholesterol.
Purpose of the Study:
- To analyze discrepancies in hypercholesterolemia treatment decisions between European guidelines and Sheffield tables.
- To evaluate the utility of the Framingham risk score in guiding lipid-lowering therapy.
Main Methods:
- Comparison of European guidelines and Sheffield tables for hypercholesterolemia treatment thresholds.
- Analysis of risk estimation methods, including coronary event risk (10-year) and coronary death risk (annual).
Main Results:
- European guidelines and Sheffield tables show discrepancies in treatment decisions due to differing criteria (morbidity vs. mortality) and trial extrapolations (4S vs. WOSCOPS).
- The Framingham coronary multivariate risk estimate is used to justify treatment if risk is sufficiently high.
Conclusions:
- Targeting lipid-lowering treatment to high-risk individuals is accepted.
- Further research is required to validate the Framingham risk profile for selecting beneficiaries and to integrate novel risk factors and atheroma detection into treatment decisions.
Background:
Evidence-based treatment of hypercholesterolemia currently recommended for rationalizing drug prescription requires justification of treatment by randomized trials, such as the West of Scotland Coronary Prevention Study (WOSCOPS) or the Scandinavian Simvastatin Survival Study (4S), and evaluation of its benefit from the estimation of the coronary risk of each patient.
Methods And Results:
The latest European guidelines and Sheffield tables apply these principles and justify the decision to treat hypercholesterolemia if the Framingham coronary multivariate risk estimate is high enough, ie, >20% risk of coronary event at 10 years in the former and >1.5% risk of coronary death per year in the latter. Nevertheless, the practice of these two recent guidelines results in discrepancies in the decision to treat, because coronary morbidity was considered in one but mortality was considered in the other, and the risk required for treating may be extrapolated from different trials (4S or WOSCOPS).
Conclusions:
Although the principle of targeting lipid-lowering treatment to high-risk subjects is unquestioned, further studies are needed to demonstrate that the Framingham risk profile is useful in selecting persons who are likely to benefit and to determine the place of newer risk factors and that of early noninvasive detection of atheroma in the risk estimation-based treatment.