Marques-Vidal, Pedro

Preisig, Martin

Vaucher, Julien

Vollenweider, Peter

Waeber, Gérard

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CURRENT OPINIONPopulation and economic impact of the 2013ACC/AHA guidelines compared with Europeanguidelines to prevent cardiovascular diseaseJulien Vaucher1*, Pedro Marques-Vidal2, Martin Preisig3, Ge´rard Waeber1†,and Peter Vollenweider1†1Department of Medicine, InternalMedicine, CHUVand Facultyof Biologyand Medicine, Baˆtiment des Instituts, Etude CoLaus, 19, rue du Bugnon, Lausanne 1005, Switzerland; 2Institute ofSocial and Preventive Medicine (IUMSP), CHUV and Faculty of Biology and Medicine, Lausanne, Switzerland; and 3Department of Psychiatry, CHUV and Faculty of Biology and Medicine,Lausanne, SwitzerlandReceived 6 January 2014; revised 28 January 2014; accepted 29 January 2014; online publish-ahead-of-print 25 February 2014Recently, the American College of Cardiology (ACC) and theAmerican Heart Association (AHA) issued new guidelines on manage-ment of cardiovascular (CV) risk in primary prevention.1 They devel-oped a new CV risk calculator [new pooled cohort atheroscleroticCV disease (CVD) risk equation] targeting individuals between40 and 75 years and based on four American population-basedcohorts.2,3 Statin treatment is recommended for individuals with anestimated 10-year risk of CVD ≥7.5%, including stroke. Conversely,the guidelines of the European Society of Cardiology (ESC) advocatethe use of the SCORE equation for individuals aged between 40 and65 years, and initiation of a statin treatment is recommended if theestimated 10-year risk of death from CVD is≥5%.4 Whether applyingthe ACC/AHA guidelines has similar public health consequences asapplying the ESC guidelines is currently unknown. Hence, we usedthe data from a large, population-based study, to assess the country-wide population and economic impact of these new guidelines,supposing full adherence to treatment recommendations.Data from the Swiss CoLaus study, collected between 2003 and2006 in 3297 participants (1854 women) aged 50–75 years, wereused.5 Ten-year CVD risk was computed according to the SwissSCORE (ESC) and the 2013 ACC/AHA risk equations; resultswere extrapolated to the Swiss population of the same age group.The Swiss SCORE equation has been validated in individuals up to75 years of age. Daily cost of treatment was estimated using onewidely used statin, i.e. atorvastatin.The results are summarized in Table 1. Irrespective of the riskequation used, the prevalence of high-risk individuals increased con-siderably with age, exceeding 80% among participants aged over 70years. Extrapolated to the Swiss population, applying the ACC/AHA guidelines more than doubled the prevalence of high-riskindividuals (2.2-fold in men and 1.9 fold in women) relative to theSCORE function. The biggest differences were observed for agegroup 50–60 years, where the ACC/AHA guidelines led to a30-fold increase in the number of high-risk individuals relative tothe ESC guidelines. Full compliance with the ACC/AHA guidelineswould also lead to an extra cost of treatment of 1.124 million CHFper day (410 million CHF, or 333.7 million E, per year).We conclude that, relative to the ESC guidelines, the 2013 ACC/AHA guidelines lead to a considerable increase in the numberof high-risk individuals susceptible of receiving statin treatment. This increaseis particularly strong in the age group 50–60 years. One likely explan-ation for this discrepancy may be due to differences in the prevalenceof CV risk factors between the USA and Europe.6,7 Consequently, iffully implemented, the ACC/AHA guidelines might lead to a con-siderable increase in primary prevention costs of CVD. Furtherstudies are needed to validate the new ACC/AHA risk equationand to assess the cost-effectiveness of the ACC/AHA guidelines innon-US countries.Authors’ contributionsJ.V. collected data and wrote most of the article. P.M.V. made the stat-istical analyses and wrote part of the article; M.P. revised the articlefor important intellectual content; G.W. and P.V. were the initiatorsof this studyand revised the article for important intellectual content.P.M.V. had full access to the data and is the guarantor of the study.FundingThe CoLaus study was supported by grants from the Swiss NationalScience Foundation (grant no: FN 33CSCO-122661 andThe opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.* Corresponding author. Tel: +41 213140346, Fax: +41 213148037, Email: julien.vaucher@chuv.ch† G.W. and P.V. contributed equally to this manuscript and are therefore both to be considered as last authors.Published on behalf of the European Society of Cardiology. All rights reserved.& The Author 2014. For permissions please email: journals.permissions@oup.comEuropean Heart Journal (2014) 35, 958–959doi:10.1093/eurheartj/ehu06433CSC0-139468); GlaxoSmithKline; the Faculty of Biology and Medicineof Lausanne, Switzerland; and the Swiss Society of Internal Medicine.Conflict of interest: G.W. and P.V. received an unrestricted grant fromGSK to build the CoLaus study. The other authors report no other con-flict of interest.References1. Stone NJ, Robinson J, Lichtenstein AH, Merz CN, Blum CB, Eckel RH, Goldberg AC,Gordon D, Levy D, Lloyd-Jones DM, McBride P, Schwartz JS, Shero ST, Smith SC Jr,Watson K, Wilson PW. 2013 ACC/AHA Guideline on the Treatment of Blood Choles-terol toReduce Atherosclerotic CardiovascularRisk inAdults: AReportof theAmericanCollege of Cardiology/American Heart Association Task Force on Practice Guidelines.Circulation 2013; doi: 10.1161/x01.cir.0000437738.63853.7a. [Epub ahead of print].2. Goff DC Jr, Lloyd-Jones DM, Bennett G, Coady S, D’Agostino RB Sr, Gibbons R,Greenland P, Lackland DT, Levy D, O’Donnell CJ, Robinson J, Schwartz JS,Shero ST, Smith SC Jr, Sorlie P, Stone NJ, Wilson PW. 2013 ACC/AHA Guidelineon the Assessment of Cardiovascular Risk: A Report of the American College of Car-diology/American Heart Association Task Force on Practice Guidelines. Circulation2013; doi: 10.1161/x01.cir.0000437741.48606.98. [Epub ahead of print].3. Goff DC Jr, Lloyd-Jones DM, Bennett G, O’Donnell CJ, Coady S, Robinson J,D’Agostino RB Sr, Schwartz JS, Gibbons R, Shero ST, Greenland P, Smith SC Jr,Lackland DT, Sorlie P, Levy D, Stone NJ, Wilson PW. 2013 ACC/AHAGuideline on the Assessment of Cardiovascular Risk: A Report of the AmericanCollege of Cardiology/American Heart Association Task Force on Practice Guide-lines. J Am Coll Cardiol 2013; doi: 10.1016/j.jacc.2013.11.005. [Epub ahead of print].4. Conroy RM, Pyorala K, Fitzgerald AP, Sans S, Menotti A, De Backer G, De Bacquer D,Ducimetiere P, Jousilahti P, Keil U, Njolstad I, Oganov RG, Thomsen T,Tunstall-Pedoe H, Tverdal A, Wedel H, Whincup P, Wilhelmsen L, Graham IM,Group Sp. Estimation of ten-year risk of fatal cardiovascular disease in Europe: theSCORE project. Eur Heart J 2003;24:987–1003.5. Firmann M, Mayor V, Vidal PM, Bochud M, Pecoud A, Hayoz D, Paccaud F, Preisig M,Song KS, Yuan X, Danoff TM, Stirnadel HA, Waterworth D, Mooser V, Waeber G,Vollenweider P. The CoLaus study: a population-based study to investigate the epi-demiology and genetic determinants of cardiovascular risk factors and metabolic syn-drome. BMC Cardiovasc Disord 2008;8:6.6. Cooney MT, Dudina AL, Graham IM. Value and limitations of existing scores for theassessment of cardiovascular risk: a review for clinicians. J Am Coll Cardiol 2009;54:1209–1227.7. Farzadfar F, Finucane MM, Danaei G, Pelizzari PM, Cowan MJ, Paciorek CJ, Singh GM,Lin JK, Stevens GA, Riley LM, Ezzati M, Global Burden of Metabolic Risk Factors ofChronic Diseases Collaborating G. National, regional, and global trends in serumtotal cholesterol since 1980: systematic analysis of health examination surveys andepidemiological studies with 321 country-years and 3.0 million participants. Lancet2011;377:578–586.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Table 1 Simulations of the population impact and of daily costs related to treatment with atorvastatin in Switzerlandaccording to the European Society of Cardiology (ESC) or 2013 American College of Cardiology and the American HeartAssociation (ACC/AHA) guidelinesSwiss population Population at riska Ratio ACC/AHA to ESCb Daily cost of treatmentcESC Men Women Total Men Women Total Men Women Total Atorvastatind(50–60) 561 013 551 105 1 112 118 8976 — e 8976 — — — 13(60–70) 429 528 448 861 878 389 204 026 29 176 233 202 — — — 350(70–75) 176 448 205 307 381 755 175 389 181 491 356 881 — — — 536All 1 814 130 1 841 332 3 655 462 388 391 210 667 599 059 — — — 899ACC/AHA(50–60) 561 013 551 105 1 112 118 274 335 23 698 298 033 30.6 NA 33.2 447(60–70) 429 528 448 861 878 389 419 649 169 221 588 869 2.1 5.8 2.5 884(70–75) 176 448 205 307 381 755 176 448 204 486 380 934 1.0 1.1 1.1 572All 1 166 989 1 205 273 2 372 262 870 432 397 405 1 267 836 2.2 1.9 2.1 2023aAccording to the ACC/AHA (new pooled cohort atherosclerotic CV disease risk equation) or ESC (Swiss SCORE equation) guidelines.bRatio of the number of subjects at risk according to ACC/AHA guidelines to the number of subjects at risk according to ESC guidelines. NA, not assessable.cExpressed in 1000 CHF. To obtain E, multiply by 0.814; to obtain USD, multiply by 1.110. Currency exchange rates as of 3 January 2014 were applied.dFixed daily price independent of dosing (10–80 mg).eSCORE equation do not predict CV risk for women under 60 years.Population impact of USA and European CVD guidelines 959

Population and economic impact of the 2013 ACC/AHA guidelines compared with European guidelines to prevent cardiovascular disease

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