American College of Physicians Guidelines on Cholesterol Screening

TO THE EDITOR:

In the 1 March 1996 issue, the American College of Physicians [1] recommends 1) limiting screening for lipid abnormalities to men aged 35 to 65 years and women aged 45 to 65 years and 2) using only the measurement of total serum cholesterol levels. The Task Force on Risk Reduction of the American Heart Association has carefully examined these new guidelines. In our view, the rationale for changing the guidelines is not justified, as we explain more thoroughly in a recent article in Circulation [2].

We suggest that physicians consider several issues before adopting these new guidelines in practice. Particularly pertinent are recent clinical trials [3, 4] showing that cholesterol-lowering therapy reduces mortality from coronary heart disease and stroke and total mortality. These trials included many persons older than 65 years of age, showing the efficacy of cholesterol reduction in decreasing mortality and improving quality of life in persons for whom the College now recommends no cholesterol testing. We strongly oppose excluding older men and women from treatment for high blood cholesterol levels. Another concern is the recommendation to ignore cholesterol levels in young adults. This approach will fail to identify persons with severely high cholesterol levels who need intensive medical therapy; it will fail to detect those who have moderately high cholesterol levels and need to modify their habits to reduce risk for premature coronary heart disease; and it overlooks the use of cholesterol testing as part of a population-based strategy to lower cholesterol levels. Well-designed research studies have shown that persons who were informed of their elevated cholesterol levels after screening increased their reading of health messages, their use of nutrition labels, and their selection of lower-fat foods.

The College's proposed guidelines put the practicing physician in an awkward position, given that numerous other professional and national bodies recommend cholesterol screening for all adults 20 years of age and older. The U.S. public and U.S. physicians generally support widespread cholesterol screening. According to the recently reported results of a telephone survey of U.S. adults done in 1995 (Schucker B. Unpublished data), 75% of persons in the United States have had their cholesterol levels checked, 65% have been told what their cholesterol levels are by physicians, and 69% know that a desirable cholesterol level is one that is less than 200 mg/dL. A parallel survey showed that 90% of U.S. physicians know their own cholesterol levels and that 67% have made dietary changes to lower their cholesterol levels. No evidence was seen of overtreatment of low-risk persons with cholesterol-lowering drugs. This survey was the last in a series of four (previous surveys were done in 1983, 1986, and 1990), all of which showed that awareness about cholesterol is increasing. This trend correlates with a population-wide decrease in blood cholesterol levels.

New and convincing research data should provide the basis for changes in guidelines as part of evidence-based medicine. Although new evidence continues to accumulate, almost all of it favors the National Cholesterol Education Program guidelines for the detection and management of hypercholesterolemia. The new recommendations by the College fail to consider all of the available scientific evidence, the public's interest, and current physician practices. We suggest that the College reconsider the rationale for these guidelines.

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