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Date: February 29, 1996 For Release: 5:00 p.m. E.S.T. Contact: NHLBI Information Office (301) 496-4236
New cholesterol screening guidelines proposed by the American College of Physicians (ACP) would deny the benefits of cholesterol lowering to large segments of the population simply on the basis of their age or sex.
The ACP guidelines, published in the March 1 issue of Annals of Internal Medicine, restrict cholesterol screening to men aged 35 to 65 and women aged 45 to 65 and do not suggest that it be mandatory in these groups even though they are entering the period of life when CHD is becoming more frequent. In addition, these guidelines recommend that only a total cholesterol level should be measured. The National Heart, Lung, and Blood Institute (NHLBI) stands by the adult screening guidelines issued by its National Cholesterol Education Program in 1993, which have been endorsed by representatives of over 40 organizations involved in cholesterol science and education. These guidelines call for total and HDL cholesterol screening for all adults age 20 and over.
The ACP guidelines downgrade the importance of cholesterol screening in young adults because their short-term risk of CHD is low. This reasoning ignores the fact that cholesterol levels in young adulthood have been shown to be valid predictors of the risk of CHD 30 to 35 years later. Finding a high cholesterol in a young adult can serve as a motivator to improve his or her pattern of diet, physical activity, and weight control and enables the physician to counsel the patient about these changes. The ACP guidelines assume that changes in life habits will not lower cholesterol and drugs will necessarily be overused. These assumptions are contrary to the available evidence. Studies have shown that knowledge of an elevated cholesterol level does lead to lifestyle changes. Recent survey results show that cholesterol lowering drugs are currently being underutilized in the U.S. rather than overused. Waiting until mid-life to treat people with a high cholesterol level will not confer all the benefits that could have been realized had lifestyle changes been made earlier.
Failing to check cholesterol levels in young adults will also miss the 1 in 500 individuals who have familial hypercholesterolemia. Without cholesterol lowering treatment, these individuals will be left to develop premature CHD. We think physicians can be trusted to measure cholesterol and do the right thing for their patients. The ACP guidelines would deny young adults the knowledge of a proven predictor of CHD, knowledge which could help them change their habits and lower their long term risk of CHD. Cholesterol screening to provide this knowledge is sound public health policy.
The ACP's exclusion of many women ignores the fact that women undergo the same basic disease process of atherosclerosis. The cut-off screening age of 65 also excludes this population when they are facing their greatest risk of coronary heart disease. For although one in ten American women ages 45 to 64 has some form of heart disease, this percentage increases to one in five for women over age 65.
The ACP guidelines also fail to screen older people. They maintain that cholesterol treatment in the older population is not justified. However, people older than 65 have the highest incidence of CHD and the risk of CHD attributable to elevated cholesterol is highest in this group. In addition, there is evidence that cholesterol lowering in older people will substantially reduce their risk of CHD. Several recent trials have found that cholesterol-lowering benefits in older individuals were similar to those in younger people. The ACP's concern about the potential hazards of drug therapy in this population should not override the importance of detecting the large number of older persons who have a very high risk of CHD and who could lower their risk if they were properly informed and treated.
The ACP's exclusion of HDL testing (except for individuals with severe atherosclerotic vascular disease) ignores the effect of low HDL levels in increasing coronary risk. Not measuring HDL will miss many individuals who should be aware that they are at increased risk.
Finally, the ACP guidelines are based on the false assumption that cholesterol lowering drug therapy does not provide a total mortality benefit in primary prevention. In fact, recent clinical trials with both coronary patients and patients without disease have found significant survival benefits from cholesterol-lowering.
The 1995 Cholesterol Awareness Survey found an impressive increase in the number of Americans who have had their blood cholesterol checked, been told their level, and know their own level. Since 1983, some 70 to 80 million Americans have become aware of their cholesterol level. This increased awareness has been a factor in the progress Americans have made in reducing their fat intakes and lowering their cholesterol levels. Implementing the ACP guidelines could adversely affect this progress.
If adopted by physicians, the ACP guidelines would prevent tens of millions of Americans from receiving the benefits of cholesterol lowering. Young adults, women, and older people would not have the opportunity to take effective action to lower their cholesterol level and reduce their risk of a future heart attack. Even middle aged men and women who are at increased risk for heart attack might fail to be tested and identified.
These guidelines fail to take a long-range prevention-oriented view of coronary disease--which develops over a lifetime. Furthermore, the guidelines are likely to confuse the public and physicians. They suggest that cholesterol lowering is not important for coronary disease prevention when, in fact, the overwhelming scientific evidence shows that it is crucial.