Coronary Heart Disease

Coronary Heart Disease

• National Guidelines and Recommendations
• Professional Groups
• Advocacy Groups

National Guidelines and Recommendations

The U.S. Preventive Services Task Force (USPSTF) Guidelines: Screening for Lipid Disorders in Adults

The USPSTF has found that there is good evidence that high levels of total cholesterol and low density lipoprotein-cholesterol (LDL-C) and low levels of high density lipoprotein-cholesterol (HDL-C) are important risk factors for coronary heart disease. The risk for coronary heart disease is highest in those with a combination of risk factors. The 10-year risk for coronary heart disease is lowest in young men and in women who do not have other risk factors, even in the presence of abnormal lipids.

The USPSTF also found good evidence that lipid measurement can identify asymptomatic men and women who are eligible for preventive therapy.

There is good evidence that lipid-lowering drug therapy substantially decreases the incidence of coronary heart disease in persons with abnormal lipids. The absolute benefits of lipid-lowering treatment depend on a person's underlying risk for coronary heart disease. Men over the age of 35 and women over the age of 45 who are at increased risk will realize a substantial benefit from treatment; younger adults with multiple risk factors for coronary disease, including dyslipidemia, will realize a moderate benefit from treatment; and younger men and women without risk factors for coronary heart disease will realize a small benefit from treatment, as seen in the risk reduction in 10-year CHD event rate.

Summary of Recommendations

Screening Men

• The U.S. Preventive Services Task Force (USPSTF) strongly recommends screening men aged 35 and older for lipid disorders.
  Rating: A recommendation
   
• The USPSTF recommends screening men aged 20 to 35 for lipid disorders if they are at increased risk for coronary heart disease.
  Rating: B recommendation

Screening Women at Increased Risk

• The USPSTF strongly recommends screening women aged 45 and older for lipid disorders if they are at increased risk for coronary heart disease.
  Rating: A recommendation
   
• The USPSTF recommends screening women aged 20 to 45 for lipid disorders if they are at increased risk for coronary heart disease.
  Rating: B recommendation

Screening Young Men and All Women Not at Increased Risk

• The USPSTF makes no recommendation for or against routine screening for lipid disorders in men aged 20 to 35, or in women aged 20 and older who are not at increased risk for coronary heart disease.
  Rating: C recommendation

Reference: Screening for Lipid Disorders in Adults, June 2008 [uspreventiveservicestaskforce.org]

U.S. Preventive Services Task Force (USPSTF) Guidelines: Screening for lipid disorders in children

The use of family history as a screening tool for dyslipidemia has variable accuracy largely because definitions of a positive family history and lipid threshold values vary substantially. Screening using family history as defined by the National Cholesterol Education Program (NCEP) and the American Academy of Pediatrics (AAP) has been shown to have high rates of false negative results.

Reference:: Screening for lipid disorders in children [ncbi.nih.gov]
U.S. Preventive Services Task Force recommendation statement. Pediatrics, 120(1):e215-9. 2007.

Reference: Screening for Lipid Disorders in Children (Cholesterol Abnormalities, Dyslipidemia) [uspreventiveservicestaskforce.org] July 2007.

U.S. Preventive Services Task Force Cholesterol Abnormalities, Dyslipidemia Screening: Systematic Evidence Review for the U.S. Preventive Services Task Force

Normal values for lipids for children and adolescents are currently defined according to population levels (percentiles). Tracking of lipid levels in children is variable, although evidence is stronger for TC and LDL than for HDL and TG. Screening using family history misses substantial numbers of children with elevated lipids. Most trials of drug interventions demonstrate improvement, but these trials were performed in selected groups of children. Several key questions could not be addressed because of lack of studies, including the effectiveness of screening on adult CHD or lipid outcomes, optimal ages and intervals for screening children, cost-effectiveness of screening, or the effects of treatment of lipids in childhood on adult CHD outcomes.

Reference: Screening for Lipid Disorders in Children and Adolescents: Systematic Evidence Review for the U.S. Preventive Services Task Force [uspreventativeservicestaskforce.org]
AHRQ Publication No. 07-0598-EF-1. July 2007.

National Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults

Third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines [nhlbi.nih.gov]

National Cholesterol Education Program - Federal Government Agency [U.S.]
National Heart, Lung, and Blood Institute (U.S.) - Federal Government Agency (U.S.)

• Research from experimental animals, laboratory investigations, epidemiology and genetic forms of hypercholesterolemia indicate that elevated low-density lipoprotein (LDL) cholesterol is a major cause of coronary heart disease (CHD).
   
• Family history of premature Congestive Heart Disease (CHD) - (CHD in male first-degree relatives 55 years of age; CHD in female first-degree relative 65 years of age) is listed as a major risk factor for hyperlipidemia and CHD.

Professional Groups

American Academy of Pediatrics

The American Academy of Pediatrics has issued new cholesterol screening and treatment recommendations for children. The policy statement, "Lipid Screening and Cardiovascular Health in Childhood," recommends cholesterol screening of children and adolescents with a family history of high cholesterol or heart disease. It also recommends screening patients whose family history is unknown or those who have other factors for heart disease including obesity, high blood pressure or diabetes. Screening should take place after age two, but no later than age 10. The best method for testing is a fasting lipid profile. If a child has values within the normal range, testing should be repeated in three to five years. For children who are more than eight years old and who have high LDL concentrations, cholesterol-reducing medications should be considered. Younger patients with elevated cholesterol readings should focus on weight reduction and increased activity while receiving nutritional counseling. The statement also recommends the use of reduced-fat dairy products, such as two percent milk, for children as young as one year of age for whom overweight or obesity is a concern.

Reference: New AAP Policy on Lipid Screening and Heart Health in Children Pediatrics, July 2008.

American College of Cardiology

Assessment of Cardiovascular Risk: A Statement for Healthcare Professionals from the American Heart Association and the American College of Cardiology [contente.onlinejacc.org]
Grundy, et al. J Am Coll Cardiol, 34:1348-59. 1999.

Risk factors for cardiovascular risk include family history of premature coronary heart disease.

Advocacy Groups

American Heart Association

Managing abnormal blood lipids. A collaborative approach
Fletcher B, Berra K, Ades P, Braun LT, Burke LE, Durstine JL, Fair JM, Fletcher GF, Goff D, Hayman LL, Hiatt WR, Miller NH, Krauss R, Kris-Etherton P, Stone N, Wilterdink J, Winston M. Circulation, 15;112(20):3184-209. 2005.

Guideline Status: This is the current release of the guideline.

Primary Prevention in Children and Youth

Identification of dyslipidemia:

• Selective screening
• Family history of coronary heart disease (CHD)
• One parent with blood cholesterol >240 mg/dL
• No parental history but CHD risk factors present
• More than of the following risk factors present:
   
  • High blood pressure
  • Smoking
  • Sedentary lifestyle
  • Obesity
  • Alcohol intake
  • Use of drugs or diseases associated with dyslipidemia

Reference:

Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update [PubMed]

Managing abnormal blood lipids. A collaborative approach [PubMed]

Lipid management in adults [guidelines.gov]

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