Guidelines for cardiovascular risk assessment and cholesterol treatment--reply.

Guidelines for Cardiovascular Risk Assessment and Cholesterol Treatment To the Editor As the chairs of the 2013 guideline panels on risk assessment and cholesterol treatment,1,2 we would like to clarify some statements made in 3 Viewpoint articles3-5 and correct some misinterpretations or incorrect assumptions. Drs Psaty and Weiss3 reviewed the evolution of recommendations on cholesterol-lowering treatment over the last several decades. They correctly emphasized aspects of the rigorous process the panels undertook with the new guidelines and reinforced the message that the purpose of risk assessment in primary prevention is to identify individuals who should undergo a “... discussion of risks, benefits, and patient preferences before starting drug therapy,”3 rather than to mandate a statin prescription. Dr Ioannidis’ perspective4 ignored the fact that 1 in 3 US residents will die of a preventable or postponable cardiovascular event. More than half of US residents will at some point have a major vascular event, which places an enormous burden on the nation’s health care system and economy. The new guidelines suggest that perhaps 30 million asymptomatic US residents without diabetes should be considered for statin therapy, whereas perhaps 70 million of them should be considered for blood pressure–lowering therapy. Until society gets much more serious about public policies that will promote cardiovascular health across the lifespan, statins and antihypertensive drugs will be needed to curb this epidemic. The Viewpoint from Dr Montori and colleagues5 made a number of incorrect statements and assumptions. The authors did not refer to the extensive discussion in the guidelines regarding the choice of the 7.5% risk threshold or the recommendation that this level of risk should trigger a risk discussion and shared decision making between clinician and patient, not routine prescription of statins. They also used the risk estimation tool for a patient who appeared to have familial hypercholesterolemia (whose 10-year risk is likely much higher than the 10% estimate), even though the guidelines explicitly state that the tools should not be applied for such a patient. Practitioners who take the time to read and understand what is actually in the guidelines, rather than what was in misleading headlines, will, we hope, find these guidelines to be very useful tools. They will advance their ability to prevent atherosclerotic cardiovascular disease (CVD) events in collaboration with their patients and, importantly, they can have confidence that the guidelines were founded based on the best available evidence.