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• W4385461005 abstract "There are multiple guideline-endorsed equations for calculating low-density lipoprotein cholesterol (LDL-C). Initiating or intensifying lipid-lowering therapy (LLT) is recommended for adults above certain cut-points including an LDL-C greater than or equal to 190 mg/dL for adults without atherosclerotic cardiovascular disease (ASCVD) or greater than or equal to 70 mg/dL for adults with ASCVD.1Grundy S.M. Stone N.J. Bailey A.L. et al.2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines.Circulation. 2019; 139: e1082-e1143PubMed Google Scholar We determined the prevalence of adults whose need for LLT intensification would be reclassified based solely on whether the Martin-Hopkins or National Institutes of Health (NIH)–2 equation was used to calculate LDL-C compared with the traditionally used Friedewald equation. The sample consisted of adults 18 years of age or older in the National Health and Nutrition Examination Survey (NHANES) from 2017 to 2020. The NHANES is a cross-sectional study that provides nationally representative estimates.2Overview of NHANES Survey Design and Weights.https://wwwn.cdc.gov/nchs/nhanes/tutorials/weighting.aspxGoogle Scholar We extracted participants’ self-reported ASCVD, defined as an affirmative response to a history of coronary artery disease, myocardial infarction, stroke, or angina. The LDL-C level was obtained from laboratory data calculated using the Friedewald, Martin-Hopkins, and NIH-2 equations in each respondent. We calculated the (1) differences in LDL-C estimates between equations, (2) proportion of participants classified as having probable familial hypercholesterolemia (LDL-C ≥190 mg/dL) by equation, and (3) proportion of participants with self-reported ASCVD and LDL-C ≥70 mg/dL by equation. All analyses were conducted in R version 4.0.2 using the survey packages following instructions from NHANES regarding survey weights and analysis approach.2Overview of NHANES Survey Design and Weights.https://wwwn.cdc.gov/nchs/nhanes/tutorials/weighting.aspxGoogle Scholar,3The Comprehensive R Archive Network.https://cran.r-project.org/Google Scholar The sample consisted of 3875 participants, representing 233,468,199 (95% CI, 207,214,514 to 259,721,884) individuals. Of these, 9.5% (95% CI, 7.8% to 11.1%, n=452) had self-reported ASCVD. The mean LDL-C by equation was 110 mg/dL (SE, 1.2) for Friedewald, 110 mg/dL (SE, 1.2) for Martin-Hopkins, and 111 mg/dL (SE, 1.2) for NIH-2. The prevalence of participants without ASCVD who had an LDL-C greater than or equal to 190 mg/dL was 2.2% (95% CI, 1.4% to 3.0%, n=85) by Friedewald, 2.3% (95% CI, 1.5% to 3.2%, n=82) by Martin-Hopkins, and 2.6% (95% CI, 1.8 to 3.5%, n=95) by NIH-2 (Table 1). In total, classification of 0.5% (95% CI, 0.2% to 0.8%, n=16) of adults whose LDL-C levels were concerning for familial hypercholesterolemia depended solely on the equation used (n=1,001,696 [95% CI, 350,199 to 1,653,193] individuals). Of participants with ASCVD, 73.7% (95% CI, 68.0% to 79.3%, n=341) by Friedewald, 77.7% (95% CI, 72.1% to 83.5%, n=353) by Martin-Hopkins, and 75.1% (95% CI, 69.6% to 80.6%, n=347) by NIH-2 had LDL-C greater than or equal to 70 mg/dL. Of these, 5.1% (95% CI 2.0% to 8.2%, n=20) of participant LDL-C classification as above or below 70 mg/dL depended solely on the equation used (n=1,128,276 [95% CI, 360,897 to 1,895,654] individuals).Table 1Prevalence of Low-density Lipoprotein Cholesterol Being Classified as Above Goal Threshold by Friedewald, Martin-Hopkins, and NIH-2 Equations% Population (95% CI)Unweighted nWeighted naTo determine full population-effect all weighted values must be multiplied by 1000. (95% CI)LDL-C Goal <70 mg/dL With ASCVD LDL-C >= 70 by equationFriedewald73.7 (68.0-79.3)34116,314 (13,028-19,601)Martin-Hopkins77.8 (72.1-83.5)35317,224 (13,544-20,903)NIH-275.1 (70.0-80.6)34716,638 (13,212-20,064) Discordance between equationsFriedewald vs NIH-21.6 (0.2-3.1)8368 (31-705)Friedewald vs Martin-Hopkins5.1 (2.0-8.2)201128 (360-1,895)LDL-C goal <190 without ASCVD LDL-C >= 190 by equationFriedewald2.2 (1.4-3.1)854749 (2967-6531)Martin-Hopkins2.3 (1.5-3.2)824929 (3034-6825) NIH-22.6 (1.8-3.5)955525 (3603-7447) Discordance between equationsFriedewald vs NIH-20.4 (0.1-0.6)10776 (170-1381)Friedewald vs Martin-Hopkins0.2 (<0.1-0.4)7437 (0-909)ASCVD, atherosclerotic cardiovascular disease; LDL-C, low-density lipoprotein cholesterol; NIH-2, National Institutes of Health 2 equation.a To determine full population-effect all weighted values must be multiplied by 1000. Open table in a new tab ASCVD, atherosclerotic cardiovascular disease; LDL-C, low-density lipoprotein cholesterol; NIH-2, National Institutes of Health 2 equation. In a nationally representative sample, Friedewald, Martins-Hopkins, or NIH-2 equations produced similar results for most patients, and only a small proportion of adults had discordant classification of their LDL-C around clinically relevant cut-points. Previous studies have shown that equation choice can impact LDL-C, and we build on this literature by contextualizing the epidemiologic relevance of those findings.4Sajja A. Li H.-F. Spinelli K.J. Blumenthal R.S. Virani S.S. Martin S.S. Gluckman T.J. Discordance between standard equations for determination of LDL cholesterol in patients with atherosclerosis.J Am Coll Cardiol. 2022; 79: 530-541Crossref Scopus (12) Google Scholar Despite there being similar pathophysiology on both sides of most medical cut-points (eg, 188 mg/dL vs 192 mg/dL), physicians have been shown to rely heavily on behavioral heuristics to inform care decisions.5Olenski A.R. Zimerman A. Coussens S. Jena A.B. Behavioral heuristics in coronary-artery bypass graft surgery.N Engl J Med. 2020; 382: 778-779Crossref PubMed Scopus (30) Google Scholar,6Blumenthal-Barby J.S. Krieger H. Cognitive biases and heuristics in medical decision making: a critical review using a systematic search strategy.Med Decis Making. 2015; 35: 539-557Crossref PubMed Google Scholar Relatedly, clinicians rely on guideline-recommended dichotomous cut-points to determine the appropriateness of LLT.1Grundy S.M. Stone N.J. Bailey A.L. et al.2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines.Circulation. 2019; 139: e1082-e1143PubMed Google Scholar As such, clinician awareness of alternative equations may help to guide management for a small but significant number of adults. Using the Martin-Hopkins or NIH-2 equation rather than the Friedewald equation may improve the identification of some adults who would benefit from intensive LLT. Dr Zheutlin is funded by the Utah Stimulating Access to Research in Residency Transition Scholar (StARRTS) under Award Number 1R38HL143605-01. The remaining authors report no potential competing interests." @default.
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• W4385461005 title "Equation-Based Low-Density Lipoprotein Cholesterol Reclassification and Implications For Lipid-Lowering Therapy" @default.
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