AHA, ACC defend guidelines, calculator

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 - Debate

The American Heart Association (AHA) and American College of Cardiology (ACC) rallied behind their recently released risk assessment and cholesterol guidelines, arguing that the calculator designed to identify patients at risk is an improvement over previous tools.

“These guidelines should enable a discussion between a patient and their healthcare provider about the best way to prevent a heart attack or stroke, based on the patient’s personal health profile and their preferences,” ACC President John Gordon Harold, MD, said in a release. “The risk calculator score is part of that discussion, because it provides specific information to the patient about their personal health.”

The associations came under fire soon after publication of four prevention guidelines that aimed to reduce the risk of cardiovascular disease. The guidelines address cardiovascular risk assessment, lifestyle management, cholesterol treatment and managing overweight and obese adults. The joint effort included a novel risk calculator and broadened the scope to include stroke prevention and patient populations not well represented in risk predictions.

The risk guidelines set a threshold of 7.5 percent or more for initiating treatment, a shift away from meeting cholesterol level targets. In an op-ed published the day after the guidelines’ publication, two physicians expressed skepticism over the calculator and guidelines. John D. Abramson, MD, of Harvard Medical School in Boston, and Rita F. Redberg, MD, of the University of California, San Francisco, wrote that the changes may result in overtreatment: “140 people in this risk group would need to be treated with statins in order to be prevent a single heart attack or stroke, without any overall reduction in serious illness. At the same time, 18 percent or more of this group would experience serious side effects.”

Others have praised the guidelines’ attempt to include minorities, women and other subpopulations that typically were not enrolled in sufficient numbers in clinical trials of cardiovascular disease.

More recently, Paul M. Ridker, MD, and Nancy Cook, MD, both of Brigham and Women’s Hospital in Boston, reported that the calculator may be flawed. The two reportedly had reviewed the risk assessment guideline and commented on what they identified as shortcomings then.

The AHA and ACC defended the guidelines Nov. 18 in a joint response. “We stand behind our guidelines, the process that was used to create them and the degree to which they were rigorously reviewed by experts,” said AHA President Mariell Jessup, MD.

Harold described the risk assessment tool as “a significant improvement” over its predecessors and emphasized its inclusion of stroke and African-Americans. He added that physicians should use the recommendations to guide decisions but that they do not replace clinical judgment. “A high score does not automatically mean a patient should be taking a statin drug,” he said.