In December 2014, the US Department of Veterans Affairs and Department of Defense (VA/DoD) published an independent clinical practice guideline for the management of dyslipidemia and cardiovascular disease risk, adding to the myriad of recently published guidelines on this topic. The VA/DoD guidelines differ from major US guidelines published by the American College of Cardiology/American Heart Association in 2013 in the following ways: recommending moderate-intensity statins for the majority of patients with statin indications regardless of atherosclerotic cardiovascular disease risk; advocating for limited on-treatment lipid monitoring; and deemphasizing ancillary data, such as coronary artery calcium testing, to improve atherosclerotic cardiovascular disease risk estimation. In the context of manifold treatment recommendations from numerous guideline committees, the VA/DoD recommendations may generate further confusion and mixed messages among healthcare providers about the optimal treatment of dyslipidemia. In this review, we critically appraise the VA/DoD recommendations with a focus on the evidence base for each area where the VA/DoD guidelines differ from the American College of Cardiology/American Heart Association guidelines. We also call for harmonization of lipid treatment guidelines to ensure high-quality and consistent care for patients with, and at risk for, atherosclerotic cardiovascular disease.
Following the 2011 dyslipidemia management guidelines from the European Society of Cardiology (ESC),1 2012 lipid guidelines from the Canadian Cardiovascular Society,2 2013 American College of Cardiology/American Heart Association (ACC/AHA) cholesterol treatment guidelines,3 2014 guidelines from the International Society of Atherosclerosis,4 and 2015 recommendations of the National Lipid Association,5 the US Department of Veterans Affairs and Department of Defense (VA/DoD) published an additional clinical practice guideline for the management of dyslipidemia and cardiovascular disease risk reduction.6 The VA/DoD guidelines were summarized in a synopsis article by Downs and O’Mally7 with the goal of reaching general practitioners and guiding cholesterol management in the primary care setting.7 However, given the myriad of other dyslipidemia guidelines recently published, it is possible the VA/DoD recommendations could generate confusion and mixed messages about the preferred treatment of dyslipidemia, most notably due to inconsistencies with the major US guideline published by the ACC/AHA in 2013.8
In this review article, we argue that widespread implementation of the VA/DoD dyslipidemia guidelines potentially could result in suboptimal management of elevated cholesterol and atherosclerotic cardiovascular disease risk by (1) prioritizing the use of moderate intensity statins for primary and secondary prevention for most patients across a broad range of risk groups (including those with a 10-year risk >12%, a 10-year risk 6%-12% with shared decision making, low-density lipoprotein cholesterol [LDL-C] ≥190 mg/dL, or diabetes with another major risk factor, eg, smoking or hypertension); (2) endorsing a statin treatment strategy that does not incorporate on-treatment LDL-C level monitoring; and (3) deemphasizing the utility of novel atherosclerotic cardiovascular disease risk factors, such as the coronary artery calcium score, to inform statin treatment decisions as part of a clinician–patient risk discussion. Finally, we also discuss our concerns regarding multiple discordant dyslipidemia guidelines that lack harmonization and may confuse providers.
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-Catherine S. Bennet, MD, Chanukya R. Dahagam, MD, Salim S. Virani, MD, PhD, Seth S. Martin, MD, MHS, Roger S. Blumenthal, MD, Erin D. Michos, MD, MHS, John W. McEvoy, MBBCh, MHS
This article originally appeared in the September 2016 issue of The American Journal of Medicine.
