November 17th, 2013

The Gaps in the (Guide)Lines?

Several Cardiology Fellows who are attending AHA.13 in Dallas this week are blogging for CardioExchange. The Fellows include Vimal RamjeeSiqin YeSeth MartinReva Balakrishnan, and  Saurav Chatterjee. You can find the previous post here. For more of our AHA.13 coverage of late-breaking clinical trials, interviews with the authors of the most important research, and blogs from our fellows on the most interesting presentations at the meeting, check out our AHA.13 Headquarters.

Along with Reva, I was also at the “Clinical Lipidology” talk this morning. The talk by Dr. Karol Watson titled, “Are there racial/ethnic considerations for statins in primary prevention?” was very instructive. I had not known, for instance, that the ideal dose of statins may be lower in Asians or that the baseline creatine kinase level can be higher in black Americans.

The talk naturally reminded me of the recently released AHA/ACC guideline for cardiovascular risk assessment. I realized, to my chagrin, that the recommendation for using the new Pooled Cohort Equations to predict cardiovascular risk falls into the “may be considered” category for myself, several of my fellow bloggers, and most of the patients I take care of in the Washington Heights neighborhood (who tend to be Hispanic/Dominican).

I think it’s great that the Guidelines frankly acknowledge this, devoting almost a page to the potential for over- and under-estimation of risk for non-white, non-African-American subgroups. But as the U.S. becomes increasingly diverse, are we also falling behind on evidence-based guidelines for a large segment of the U.S. population?

Another way to look at this issue may be to acknowledge the inherent challenges of applying population estimates to individuals. As Joseph Ladapo pointed out recently, we still know very little about how to quantify within-individual uncertainty when estimating risk. So perhaps what we really need is not the perfectly calibrated equation but a better understanding of how to engage our patients under conditions of uncertainty to make the best patient-centered decisions?

What’s your take on the best way to adopt the new guidelines? Share your ideas with the CardioExchange community.

One Response to “The Gaps in the (Guide)Lines?”

  1. Siqin Ye, MD says:

    This NYT article just came out about calibration issues for the Pooled Cohort Equations. I imagine there will be extensive discussions on this in the next few days. I’m curious to see the data, as the Lancet article appears to not have been uploaded yet.

    I also played around with the calculator a bit, to test Dr. Nissen’s point at the end of the article. If all the risk factors are entered as “Optimal values”, a non-Hispanic white man 63 years old or greater will have 10-year ASCVD risk >=7.5%; the same is true for an African-American man 66 years old or greater. So should we discuss statin therapy with most of our male Medicare patients?

    [A final thought on this: it’s always disheartening to see in the comments sections of these kinds of articles the common misconception that doctor’s main motivations are profit driven. I left a short rebuttal, which hopefully will be cleared to appear!]