Welcome to NGC. Skip directly to: Search Box, Navigation, Content.
INTRODUCTION
A direct comparison of the U.S. Preventive Services Task Force (USPSTF) and Department of Veterans Affairs, Department of Defense (VA/DoD) recommendations for lipid screening in adults is provided in the tables below. The VA/DoD guideline also provides recommendations for the management of dyslipidemia. This topic, however, is beyond the scope of this synthesis.
Following the content comparison tables and discussion, the areas of agreement and areas of differences among the guidelines are identified.
Listed below are common abbreviations used within the tables and discussions:
TABLE 1: COMPARISON OF INTERVENTIONS AND PRACTICES CONSIDERED ("" indicates topic is addressed) |
||||
---|---|---|---|---|
USPSTF (2008) |
VA/DoD (2006) |
|||
Whom to Screen |
||||
Screening Test |
||||
Risk Factors for CHD to be Assessed |
||||
Screening Interval |
TABLE 5: EVIDENCE AND RECOMMENDATION RATING SCHEMES | ||||||||||||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
USPSTF (2008) |
Definitions: The U.S. Preventive Services Task Force (USPSTF) grades its recommendations according to one of five classifications (A, B, C, D, or I), reflecting the strength of evidence and magnitude of net benefit (benefits minus harms). A The U.S. Preventive Services Task Force (USPSTF) strongly recommends that clinicians provide [the service] to eligible patients. (The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms.) B The USPSTF recommends that clinicians provide [the service] to eligible patients. (The USPSTF found at least fair evidence that [the service] improves health outcomes and concludes that benefits outweigh harms.) C The USPSTF makes no recommendation for or against routine provision of [the service]. (The US Preventive Services Task Force found at least fair evidence that [the service] can improve health outcomes but concludes that the balance of benefits and harms it too close to justify a general recommendation.) D The USPSTF recommends against routinely providing [the service] to asymptomatic patients. (The USPSTF found at least fair evidence that [the service] is ineffective or that harms outweigh benefits.) I The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing [the service]. (Evidence that [the service] is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.) The USPSTF grades the quality of the overall evidence for a service on a 3-point scale (good, fair, or poor). Good Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes. Fair Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies; generalizability to routine practice; or indirect nature of evidence on health outcomes. Poor Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes. |
|||||||||||||||||||||||||
VA/DoD (2006) |
Strength of the Recommendations A: A strong recommendation that the clinicians provide the intervention to eligible patients. B: A recommendation that clinicians provide (the service) to eligible patients. C: No recommendation for or against the routine provision of the intervention is made. D: Recommendation is made against routinely providing the intervention to asymptomatic patients. I: The conclusion is that the evidence is insufficient to recommend for or against routinely providing the intervention.
Quality of Evidence I: At least one properly done randomized controlled trial II-1: Well designed controlled trails without randomization II-2: Well designed cohort or case-control analytic study, preferably from more than one source II-3: Multiple time series evidence with/without intervention; dramatic results of uncontrolled experiment III: Opinion of respected authorities, descriptive studies, case reports, and expert committees Overall Quality Good: High grade evidence (I or II-1) directly linked to health outcome Fair: High grade evidence (I or II-1) linked to intermediate outcome; or moderate grade evidence (II-2 or II-3) directly linked to health outcome Poor: Level III evidence or no linkage of evidence to health outcome Net Effect of Intervention Substantial:
Moderate:
Small:
Zero or Negative:
References Supporting the Recommendations 27th Bethesda Conference. Matching the Intensity of Risk Factor Management with the Hazard for Coronary Disease Events. September 14-15, 1995. J Am Coll Cardiol 1996 Apr;27(5):957-1047. PubMed A multicenter comparative trial of lovastatin and pravastatin in the treatment of hypercholesterolemia. The Lovastatin Pravastatin Study Group. Am J Cardiol 1993 Apr 1;71(10):810-5. PubMed Downs JR, Clearfield M, Weis S, Whitney E, Shapiro DR, Beere PA, Langendorfer A, Stein EA, Kruyer W, Gotto AM Jr. Primary prevention of acute coronary events with lovastatin in men and women with average cholesterol levels: results of AFCAPS/TexCAPS. Air Force/Texas Coronary Atherosclerosis Prevention Study. JAMA 1998 May 27;279(20):1615-22. PubMed Ford DE, Mead LA, Chang PP, Cooper-Patrick L, Wang NY, Klag MJ. Depression is a risk factor for coronary artery disease in men: the precursors study. Arch Intern Med 1998 Jul 13;158(13):1422-6. PubMed Greenland P, Abrams J, Aurigemma GP, Bond MG, Clark LT, Criqui MH, Crouse JR 3rd, Friedman L, Fuster V, Herrington DM, Kuller LH, Ridker PM, Roberts WC, Stanford W, Stone N, Swan HJ, Taubert KA, Wexler L. Prevention Conference V: beyond secondary prevention: identifying the high-risk patient for primary prevention: noninvasive tests of atherosclerotic burden: Writing Group III. Circulation 2000 Jan 4;101(1):E16-22. PubMed Greenland P, LaBree L, Azen SP, Doherty TM, Detrano RC. Coronary artery calcium score combined with Framingham score for risk prediction in asymptomatic individuals. JAMA 2004 Jan 14;291(2):210-5. PubMed Grover SA, Coupal L, Hu XP. Identifying adults at increased risk of coronary disease. How well do the current cholesterol guidelines work?. JAMA 1995 Sep 13;274(10):801-6. PubMed Grover SA, Dorais M, Paradis G, Fodor JG, Frohlich JJ, McPherson R, Coupal L, Zowall H. Lipid screening to prevent coronary artery disease: a quantitative evaluation of evolving guidelines. CMAJ 2000 Nov 14;163(10):1263-9. PubMed Grundy SM, Cleeman JI, Merz CN, Brewer HB Jr, Clark LT, Hunninghake DB, Pasternak RC, Smith SC Jr, Stone NJ. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 2004 Jul 13;110(2):227-39. [45 references] PubMed Grundy SM, Pasternak R, Greenland P, Smith S Jr, Fuster V. Assessment of cardiovascular risk by use of multiple-risk-factor assessment equations: a statement for healthcare professionals from the American Heart Association and the American College of Cardiology. Circulation 1999 Sep 28;100(13):1481-92. [115 references] PubMed Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet 2002 Jul 6;360(9326):7-22. PubMed O'Donnell CJ. Family history, subclinical atherosclerosis, and coronary heart disease risk: barriers and opportunities for the use of family history information in risk prediction and prevention. Circulation 2004 Oct 12;110(15):2074-6. PubMed Pearson TA, Mensah GA, Alexander RW, Anderson JL, Cannon RO 3rd, Criqui M, Fadl YY, Fortmann SP, Hong Y, Myers GL, Rifai N, Smith SC Jr, Taubert K, Tracy RP, Vinicor F. Markers of inflammation and cardiovascular disease: application to clinical and public health practice: A statement for healthcare professionals from the Centers for Disease Control and Prevention and the American Heart Association. Circulation 2003 Jan 28;107(3):499-511. PubMed Pignone MP, Phillips CJ, Atkins D, Teutsch SM, Mulrow CD, Lohr KN. Screening and treating adults for lipid disorders. Am J Prev Med 2001 Apr;20(3 Suppl):77-89. [62 references] PubMed Pletcher MJ, Tice JA, Pignone M, Browner WS. Using the coronary artery calcium score to predict coronary heart disease events: a systematic review and meta-analysis. Arch Intern Med 2004 Jun 28;164(12):1285-92. PubMed Ridker PM. High-sensitivity C-reactive protein: potential adjunct for global risk assessment in the primary prevention of cardiovascular disease. Circulation 2001 Apr 3;103(13):1813-8. PubMed Screening experience and baseline characteristics in the West of Scotland Coronary Prevention Study. The WOSCOPS Study Group. West of Scotland Coronary Prevention Study. Am J Cardiol 1995 Sep 1;76(7):485-91. PubMed Sever PS, Dahlof B, Poulter NR, Wedel H, Beevers G, Caulfield M, Collins R, Kjeldsen SE, Kristinsson A, McInnes GT, Mehlsen J, Nieminen M, O'Brien E, Ostergren J. Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have average or lower-than-average cholesterol concentrations, in the Anglo-Scandinian Cardiac Outcomes Trial - Lipid Lowering Arm (ASCOT-LLA): a multicentre [trunc]. Lancet 2003 Apr 5;361(9364):1149-58. PubMed Sheridan S, Pignone M, Mulrow C. Framingham-based tools to calculate the global risk of coronary heart disease: a systematic review of tools for clinicians. J Gen Intern Med 2003 Dec;18(12):1039-52. [58 references] PubMed Stone NJ, Blum C, Winslow E. Management of lipids in clinical practice. Oklahoma: Professional Communications Inc.; 1997. Stone NJ, Blum CB. Management of lipids in clinical practice. West Islip (NY): Professional Communications Inc.; 2002. 115-20 p. 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) final report. Circulation 2002 Dec 17;106(25):3143-421. PubMed US Preventive Services Task Force. Screening adults for lipid disorders: recommendations and rationale. Am J Prev Med 2001 Apr;20(3 Suppl):73-6. PubMed Wilson PW, D'Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation 1998 May 12;97(18):1837-47. PubMed |
The United States Preventive Services Task Force (USPSTF) and the Department of Veterans Affairs, Department of Defense (VA/DoD) present recommendations for screening for high lipid disorders in adults. The VA/DoD guideline also contains recommendations for the management of dyslipidemia. This topic, however, is beyond the scope of this synthesis.
The guidelines describe the clinical evidence and give explicit reasoning for their recommendations.
Men
Both groups recommend that all men aged 35 and older, regardless of risk level, should be screened for lipid disorders. There is also agreement that men younger than 35 at increased risk for CHD should be screened. With regard to average risk men younger than 35, USPSTF makes no recommendation for or against routine screening. VA/DoD does not provide a recommendation for routine screening in this population.
Women
Both groups agree that all women at increased risk of CHD should be screened.
Refer to Areas of Differences below for discussion of screening in women at average risk of CHD.
Older Adults
USPSTF states that an age to stop screening has not been established. VA/DoD refers to USPSTF, noting that USPSTF has not established an age at which to stop screening for primary prevention, and therefore, screening beyond age 75 should be left to clinical considerations.
Recommendations regarding screening frequency are similar. USPSTF states that the optimal interval for screening is uncertain, but that reasonable options include every 5 years, with shorter intervals for people who have lipid levels close to warranting therapy, and longer intervals at those not at increased risk who have had repeatedly normal lipid levels. VA/DoD similarly notes that patients with average or below average risk should be screened every 5 years, and patients with risk factors should be screened more frequently. VA/DoD explicitly recommends annual screening for middle aged adults (men > age 35; women > age 45) if CVD risk factors exist.
Women
While both groups recommend screening of all women at increased risk of CHD, VA/DoD also recommends routine screening of women older than 45 at average risk. USPSTF makes no recommendation for or against routine screening in women who are not at increased risk for CHD.
Recommendations regarding which screening tests should be performed differ. According to USPSTF, the preferred screening tests are TC and HDL-C on fasting or non-fasting samples. They add that there is currently insufficient evidence of the benefit of including TG as a part of the initial tests used to screen routinely for dyslipidemia. VA/DoD, in contrast to USPSTF, recommends screening on a fasting sample for TG (in order to calculate LDL-C) in addition to TC and HDL-C. VA/DoD notes that, in recommending measurement of LDL-C for screening purposes, its current recommendation differs from its previous (1999) statement.
This synthesis was prepared by NGC on July 28, 2000. It was reviewed by the guideline developers as of October 10, 2000. It has been modified a number of times. This synthesis was revised in November 2008 to remove NHLBI recommendations and to add USPSTF recommendations. This synthesis was verified by USPSTF on December 29, 2008.
Internet citation: National Guideline Clearinghouse (NGC). Guideline synthesis: Screening for lipid disorders in adults. In: National Guideline Clearinghouse (NGC) [website]. Rockville (MD): 2000 Oct 10. (updated 2009 Jan) [cited YYYY Mon DD]. Available: http://www.guideline.gov.