Aims: Population-wide impacts of new guidelines in the primary prevention of atherosclerotic cardiovascular disease (ASCVD) should be explored in independent cohorts. Assess and compare the lipid-lowering therapy eligibility and predictive classification performance of 2016 and 2021 European Society of Cardiology (ESC), 2019 American Heart Association/American College of Cardiology (AHA/ACC), and 2022 US Preventive Services Task Force (USPSTF) guidelines.
Methods and results: Participants from the CoLaus|PsyCoLaus study, without ASCVD and not taking lipid-lowering therapy at baseline. Derivation of 10-year risk for ASCVD using Systematic COronary Risk Evaluation (SCORE1), SCORE2 [including SCORE2-Older Persons (SCORE2-OP)], and pooled cohort equation. Computation of the number of people eligible for lipid-lowering therapy based on each guideline and assessment of discrimination and calibration metrics of the risk models using first incident ASCVD as an outcome. Among 4,092 individuals, 158 (3.9%) experienced an incident ASCVD during a median follow-up of 9 years (interquartile range, 1.1). Lipid-lowering therapy was recommended or considered in 40.2% (95% confidence interval, 38.2-42.2), 26.4% (24.6-28.2), 28.6% (26.7-30.5), and 22.6% (20.9-24.4) of women and in 62.1% (59.8-64.3), 58.7% (56.4-61.0), 52.6% (50.3-54.9), and 48.4% (46.1-50.7) of men according to the 2016 ESC, 2021 ESC, 2019 AHA/ACC, and 2022 USPSTF guidelines, respectively. 43.3 and 46.7% of women facing an incident ASCVD were not eligible for lipid-lowering therapy at baseline according to the 2021 ESC and 2022 USPSTF, compared with 21.7 and 38.3% using the 2016 ESC and 2019 AHA/ACC, respectively.
Conclusion: Both the 2022 USPSTF and 2021 ESC guidelines particularly reduced lipid-lowering therapy eligibility in women. Nearly half of women who faced an incident ASCVD were not eligible for lipid-lowering therapy.
Keywords: Cardiovascular; Guidelines; Lipid-lowering therapy; Primary prevention; Risk score; Validation.
Question: Compared with previous European and US guidelines, what are the population-wide impacts of the 2021 European Society of Cardiology (ESC) and 2022 US Preventive Services Task Force (USPSTF) guidelines for primary cardiovascular prevention in terms of lipid-lowering therapy eligibility and risk classification performance?
Key findings: In a population-based cohort study comprising 4069 adults free from cardiovascular disease and lipid-lowering treatment, the implementation of both guidelines resulted in a lower proportion of treatment-eligible individuals compared with the 2016 ESC and 2019 American Heart Association/American College of Cardiology guidelines, especially among women. In women, nearly half of 10-year incident cardiovascular events occurred in those for whom a lipid-lowering therapy was not recommended. Meanings: The 2021 ESC and 2022 USPSTF guidelines reduced overtreatment but did not improve the identification of individuals who will develop atherosclerotic cardiovascular disease. There is a need to better stratify the cardiovascular risk in women.
© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.