ESC/EAS statin eligibility criteria in primary prevention should include very high TG levels
Unmet need for primary prevention in individuals with hypertriglyceridaemia not eligible for statin therapy according to European Society of Cardiology/European Atherosclerosis Society guidelines: a contemporary population-based studyLiterature - Madsen CM, Varbo A, Nordestgaard BG. - Eur Heart J 2017; published online ahead of print
- During 456 057 person-years of follow-up, the overall incidence rate of MACE was 3.9 (95% CI: 3.7–4.1) per 1000 person-years (PY), and the incidence of MI was 1.6 (1.5–1.7) per 1000 PY.
- According to 2016 EAS/ESC criteria, 14% of individuals were definite statin eligible. Among individuals who were not definite statin eligible, 8% had TG levels >3mmol/L (264mg/dL).
- The 2016 ESC/EAS guideline to treat individuals with very high risk and TGs >2.3mmol/L (202mg/dL) pharmacologically, would apply to only 209 individuals (0.4%) not already definite statin eligible by the LDL-C criteria.
- The incidence rates of MACE and MI increased with increasing concentrations of TGs. Individuals who were not definite statin eligible and had TGs <1.0mmol/L (88mg/dL) had the lowest incidence rates of MACE (2.2; 95% CI: 1.9–2.5) and MI (0.6; 95% CI: 0.5–0.8) per 1000 PY.
- Individuals with TGs of 4.0–4.99mmol/L (352–439mg/dL) had the highest incidence rates of MACE (7.9; 95% CI: 6.0–10.3) and MI (4.3; 95% CI: 3.0–6.2) per 1000 PY, which were similar to the rates for definite statin eligible individuals. The estimated 10-year risks of MACE and MI showed a similar pattern as for the incidence rates.
- Using a cut-off value of 3.0mmol/L (264mg/dL) in individuals who were not definite statin eligible showed that those with TGs ≥ 3mmol/L have similar risks of MACE and MI to definite statin eligible individuals (P=0.75 and P= 0.42), and higher risks than in those with TGs <3.0mmol/L (P< 0.0001 for both endpoints).
In a large population-based study, high TG levels identified individuals at high risk of ASCVD, who would not be definite eligible for statin treatment according to the 2016 ESC/EAS guidelines. These results suggest that guidelines on statin eligibility in primary prevention might have to be expanded to individuals with hypertriglyceridemia.