• U.S. Preventive Services Task Force. Screening for lipid disorders in adults: U.S. Preventive Services Task Force recommendation statement. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2008 Jun. 13 p. [17 references]

This is the current release of the guideline.

This guideline updates a previous version: Berg AO. Screening adults for lipid disorders. Recommendations and rationale. Am J Prev Med 2001 Apr;20(3 Suppl):73-6. [12 references]

• Lipid disorders
• Coronary heart disease

Prevention
Risk Assessment
Screening

Family Practice
Internal Medicine
Preventive Medicine

Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Nurses
Physician Assistants
Physicians

• To summarize the U.S. Preventive Services Task Force (USPSTF) recommendations and supporting scientific evidence on screening for lipid disorders in adults
• To update the 2001 USPSTF recommendations on screening for lipid disorders in adults

Adults aged 20 years and older who have not previously been diagnosed with dyslipidemia

Screening for lipid disorders using measurement of total cholesterol and high-density lipoprotein cholesterol on nonfasting or fasting blood samples.

Note: Measurement of low-density lipoprotein cholesterol and triglycerides are also considered.

Key Question 1: How frequent is elevated total cholesterol in men younger than age 35 and women younger than age 40, and what proportion have an overall 10-year risk of cardiac events of 10% or greater?

Key Question 2: What evidence supports the use of triglyceride levels as part of an initial screening panel?

Key Question 3: What are the optimal screening intervals in the general population and in patients at high risk for coronary heart disease (CHD) events?

Key Question 4: What risk factors should be used to select patients for drug therapy?

Key Question 5: What is the current evidence about the harms of drug therapy for lipid disorders?

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Note from the National Guideline Clearinghouse (NGC) and the U.S. Preventive Services Task Force (USPSTF): A selective review of the literature was prepared by Oregon Evidence-based Practice Center (EPC) for use by the USPSTF (see the "Availability of Companion Documents" field). In this selective update, new evidence available since the publication of the USPSTF 2001 recommendations on screening for lipid disorders in adults was reviewed. This document should be read in conjunction with the full systematic evidence review conducted for the USPSTF in 2001 (see the "Availability of Companion Documents" field), the final report of National Cholesterol Education Project Adult Treatment Panel III (ATP III), and the 2004 ATP III update. These other reports provide more detailed and thorough analysis than can be provided here. The main findings of this update, focusing on discrepancies between the USPSTF recommendations and ATP III and summarized in Table 1 of the 2008 Evidence Review, should be viewed in this context.

Data Sources

The 2001 systematic evidence review prepared for the USPSTF (see the "Availability of Companion Documents" field) was based on searches of MEDLINE (1994 to December 1999) and the Cochrane Controlled Trials Registry through December 1, 1999. For this update, EPC staff searched the Cochrane Library (2004, Issue 4), MEDLINE (1966-February Week 1 2005), EMBASE (1980-February 4, 2005), PREMEDLINE (through February 9, 2005), and dossiers submitted by manufacturers of statins (see Appendix 1 of the 2008 Evidence Review [see "Availability of Companion Documents" field]). To identify key articles about the epidemiology, natural history, and detection of lipid levels and lipid disorders, EPC staff relied on the reference lists of the 2002 National Cholesterol Education Project Adult Treatment Panel III (ATP III) Final Report and the 2004 update to ATP III, as well as recent systematic reviews, supplemented by a title and abstract search of MEDLINE and PREMEDLINE. All searches were restricted to articles published in English.

Study Selection

EPC staff reviewed randomized trials of at least a 1-year duration that examined drug therapy with statins among patients without previously known CHD, and measured clinical end points including total mortality, coronary heart disease (CHD) mortality, and nonfatal myocardial infarction (MI). To be included, the trial had to address primary prevention in the general population or in a subset of the general population identified on the basis of risk factors for CHD. Observational studies of the epidemiology of lipid disorders, screening to detect lipid disorders, risk factors for CHD, and the harms of statin therapy were also included.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

The U.S. Preventive Services Task Force (USPSTF) grades the quality of the overall evidence 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.

Review of Published Meta-Analyses
Systematic Review with Evidence Tables

Note from the National Guideline Clearinghouse (NGC) and the U.S. Preventive Services Task Force (USPSTF): A selective review of the literature was prepared by Oregon Evidence-based Practice Center (EPC) for use by the USPSTF (see the "Availability of Companion Documents" field). In this selective update, new evidence available since the publication of the USPSTF 2001 recommendations on screening for lipid disorders in adults was reviewed. This document should be read in conjunction with the full systematic evidence review conducted for the USPSTF in 2001 (see the "Availability of Companion Documents" field), the final report of National Cholesterol Education Project Adult Treatment Panel III (ATP III), and the 2004 ATP III update. These other reports provide more detailed and thorough analysis than can be provided here. The main findings of this update, focusing on discrepancies between the USPSTF recommendations and ATP III and summarized in Table 1 of the 2008 Evidence Review, should be viewed in this context.

Data Extraction and Quality Assessment

EPC staff used text and internal validity ratings from a previous review of statins to summarize the results of recent statin trials and of the safety of statins. They used standard USPSTF methods to rate the internal validity of trials and epidemiologic studies included in this update but not in the statins review (See Appendix 2 of the 2007 Evidence Review [see the "Availability of Companion Documents" field]).

Data Synthesis and Analysis

EPC staff summarized new evidence relevant to discrepancies between USPSTF and ATP III recommendations in the context of earlier evidence from the 2001 evidence review conducted for the USPSTF, the final report of ATP III, and the 2004 ATP III update.

Balance Sheets
Expert Consensus

When the overall quality of the evidence is judged to be good or fair, the U.S. Preventive Services Task Force (USPSTF) proceeds to consider the magnitude of net benefit to be expected from implementation of the preventive service. Determining net benefit requires assessing both the magnitude of benefits and the magnitude of harms and weighing the two.

The USPSTF classifies benefits, harms, and net benefits on a 4-point scale: "substantial," "moderate," "small," and "zero/negative."

"Outcomes tables" (similar to 'balance sheets') are the USPSTF's standard resource for estimating the magnitude of benefit. These tables, prepared by the topic teams for use at USPSTF meetings, compare the condition specific outcomes expected for a hypothetical primary care population with and without use of the preventive service. These comparisons may be extended to consider only people of specified age or risk groups or other aspects of implementation. Thus, outcomes tables allow the USPSTF to examine directly how the preventive services affect benefits for various groups.

When evidence on harms is available, the topic teams assess its quality in a manner like that for benefits and include adverse events in the outcomes tables. When few harms data are available, the USPSTF does not assume that harms are small or nonexistent. It recognizes a responsibility to consider which harms are likely and judge their potential frequency and the severity that might ensue from implementing the service. It uses whatever evidence exists to construct a general confidence interval on the 4-point scale (e.g., substantial, moderate, small, and zero/negative).

Value judgments are involved in using the information in an outcomes table to rate either benefits or harms on the USPSTF's 4-point scale. Value judgments are also needed to weigh benefits against harms to arrive a rating of net benefit.

In making its determinations of net benefit, the USPSTF strives to consider what it believes are the general values of most people. It does this with greater confidence for certain outcomes (e.g., death) about which there is little disagreement about undesirability, but it recognizes that the degree of risk people are willing to accept to avert other outcomes (e.g., cataracts) can vary considerably. When the USPSTF perceives that preferences among individuals vary greatly, and that these variations are sufficient to make trade-off of benefits and harms a 'close-call', then it will often assign a C recommendation (see the "Recommendation Rating Scheme" field). This recommendation indicates the decision is likely to be sensitive to individual patient preferences.

The USPSTF uses its assessment of the evidence and magnitude of net benefit to make recommendations. The general principles the USPSTF follows in making recommendations are outlined in Table 5 of the companion document cited below. The USPSTF liaisons on the topic team compose the first drafts of the recommendations and rationale statements, which the full panel then reviews and edits. Recommendations are based on formal voting procedures that include explicit rules for determining the views of the majority.

From: Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow, CD, Teutsch SM, Atkins D. Current methods of the U.S. Preventive Services Task Force: a review of the process. Methods Work Group, Third U.S. Preventive Services Task Force. Am J Prev Med 2001 Apr;20(3S):21-35.

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 USPSTF 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.)

A formal cost analysis was not performed and published cost analyses were not reviewed.

Comparison with Guidelines from Other Groups
External Peer Review
Internal Peer Review

Peer Review. Before the U.S. Preventive Services Task Force makes its final determinations about recommendations on a given preventive service, the Evidence-based Practice Center and the Agency for Healthcare Research and Quality send a draft systematic evidence review to 4 to 6 external experts and to federal agencies and professional and disease-based health organizations with interests in the topic. They ask the experts to examine the review critically for accuracy and completeness and to respond to a series of specific questions about the document. After assembling these external review comments and documenting the proposed response to key comments, the topic team presents this information to the Task Force in memo form. In this way, the Task Force can consider these external comments and a final version of the systematic review before it votes on its recommendations about the service. Draft recommendations are then circulated for comment from reviewers representing professional societies, voluntary organizations and federal agencies. These comments are discussed before the whole U.S. Preventive Services Task Force before final recommendations are confirmed.

Recommendations of Others. Recommendations for screening for lipid disorders from the following groups were discussed: National Cholesterol Education Program's Adult Treatment Panel III, sponsored by the National Institutes of Health and endorsed by the American Heart Association; the American Academy of Family Physicians; and the American College of Obstetricians and Gynecologists.

None provided

The type of evidence supporting each recommendation is identified in the "Major Recommendations" field.

Benefits of Detection and Early Treatment

There is good evidence that lipid-lowering drug therapy substantially decreases the incidence of coronary heart disease in persons with abnormal lipids. The absolute benefits of lipid-lowering treatment depend on a person's underlying risk for coronary heart disease. Men over the age of 35 and women over the age of 45 who are at increased risk will realize a substantial benefit from treatment; younger adults with multiple risk factors for coronary disease, including dyslipidemia, will realize a moderate benefit from treatment; and younger men and women without risk factors for coronary heart disease will realize a small benefit from treatment, as seen in the risk reduction in 10-year coronary heart disease (CHD) event rate.

Harms of Detection and Early Treatment

There is good evidence that the harms from screening and treatment are small and include possible labeling and the adverse effects associated with lipid-lowering therapy (e.g., rhabdomyolysis).

Staying Healthy

Effectiveness
Patient-centeredness

• U.S. Preventive Services Task Force. Screening for lipid disorders in adults: U.S. Preventive Services Task Force recommendation statement. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2008 Jun. 13 p. [17 references]

Not applicable: The guideline was not adapted from another source.

1996 (revised 2008 Jun)

United States Preventive Services Task Force - Independent Expert Panel

The U.S. Preventive Services Task Force (USPSTF) is a federally-appointed panel of independent experts. Conclusions of the U.S. Preventive Services Task Force do not necessarily reflect policy of the U.S. Department of Health and Human Services (DHHS) or its agencies.

United States Government

U.S. Preventive Services Task Force (USPSTF)

The U.S. Preventive Services Task force has an explicit policy concerning conflict of interest. All members disclose at each meeting if they have an important financial conflict for each topic being discussed. Task Force members with conflicts can participate in discussions about evidence, but members abstain from voting on recommendations about the topic in question.

From: Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow, CD, Teutsch SM, Atkins D. Current methods of the U.S. Preventive Services Task Force: a review of the process. Methods Work Group, Third U.S. Preventive Services Task Force. Am J Prev Med 2001 Apr;20(3S):21-35.

This is the current release of the guideline.

This guideline updates a previous version: Berg AO. Screening adults for lipid disorders. Recommendations and rationale. Am J Prev Med 2001 Apr;20(3 Suppl):73-6. [12 references]

This summary was completed by ECRI on April 6, 2001. The information was verified by the guideline developer as of April 10, 2001. This NGC summary was updated by ECRI Institute on June 12, 2008. The updated information was verified by the guideline developer on June 16, 2008.