Durham, NC—Whether statins are prescribed to certain middle aged Americans—more than a fourth of them having a diabetes diagnosis—is determined by which national guidelines are being followed.

A JAMA article notes that, overall, fewer patients would get preventative stains if their physicians adhere to the 2016 United States Preventive Services Task Force (USPSTF) recommendations for statin therapy versus the 2013 American College of Cardiology/American Heart Association guidelines.

While the ACC/AHA guidelines significantly increased the population eligible for statin therapy by basing recommendations on an elevated 10-year risk of atherosclerotic cardiovascular disease (ASCVD), the USPSTF recommendations upped the estimated ASCVD risk threshold for patients—including those with diabetes—while also requiring the presence of at least one cardiovascular risk factor such as hypertension, diabetes, dyslipidemia, or smoking.

Based on their comparison, Duke University–led researchers report that, with full implementations, the USPSTF recommendations would result in statin initiation in 16% of adults without prior cardiovascular disease (CVD), on top of the 22% of adults already taking lipid-lowering therapy. On the other hand, universal adoption of the ACC/AHA guidelines would lead to statin initiation in an additional 24% of patients.

That means that 8.9% of the population would be recommended for statins by the ACC/AHA guidelines, but not by USPSTF recommendations. And, study authors point out, 55% of adults are aged 40 to 59 years with an average 30-year cardiovascular risk greater than 30%—with 28% of them having a diabetes diagnosis.

“Having multiple guidelines out there for cholesterol-lowering drugs can be confusing to physicians and patients,” explained lead author Neha J. Pagidipati, MD, of the Duke Clinical Research Institute. “Until we get more definitive answers about the optimal approach, the best we can do is understand the pros and cons of each set of guidelines. Our study adds some of that context.”

The study looked at a nationally representative sample of 3,416 U.S. adults ages 40 to 75 years with fasting lipid data and triglyceride levels of 400 mg/dL or less, without prior CVD.

“If these estimates are accurate and assuming these proportions can be projected to the U.S. population, there could be an estimated 17.1 million vs 26.4 million U.S. adults with a new recommendation for statin therapy, based on the USPSTF recommendations vs the ACC/AHA guideline recommendations, respectively—an estimated difference of 9.3 million individuals,” the authors write. “Alternative approaches to augmenting risk-based cholesterol guidelines, including those that explicitly incorporate potential benefit of therapy, should be considered.”

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