So there it is, and it all does make a certain amount of sense. You first determine the patient’s risk category, which determines whether or not statins are indicated. If they are, you then decide what level of potency your prescribed statin should possess. There is no need to go checking LDL-C levels later, because your therapy is not targeted at any particular LDL-C level. You might want to check occasionally, though, just as a way of assessing patient compliance.
So what should we make of all of this? From a purely scientific point of view, it seems abundantly clear that these are the most scientifically valid set of guidelines that have ever been produced, generated by genuine experts who bent over backward to examine every possible relevant study. The new risk calculator is clearly a broader-based tool than the Framingham calculator, which was based on now-dated data from a very narrow heavily-white population basis. Although the new risk calculator has been criticized by some as a very imperfect tool that overestimates risk in some subpopulations, I firmly believe it is considerably less imperfect than the Framingham tool. It is, quite frankly, the best risk calculator anyone could come up with at this time, and the cutoff for treatment at a risk of 7.5% or higher over 10 years seems eminently reasonable to me.
So what’s the problem with the new guidelines? I think you astute readers already know what the problem is: These guidelines simply represent way too radical a change for the huge bulk of busy, harried providers out there. The average primary care provider is currently struggling to complete a multifaceted patient encounter in 15 minutes or less and then document it in excruciating detail. He or she is going to be extremely hard-pressed to master and implement the new guidelines. The guidelines are indeed the most scientifically accurate and thorough guidelines that could be humanly produced, but they represent such a radical change from previous guidelines that a huge number of providers are going to be playing catch-up for a long time. I hope that their learning curve can be a very rapid one, but I worry that these scientifically pristine guidelines will be slow to find their way into general practice.
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The author reports no actual or potential conflicts of interest with regard to this article.
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