Cholesterol screening guidelines: Consensus, evidence, and common sense

In a previous issue of Circulation, the Task Force on Risk Reduction criticized the updated American College of Physicians (ACP) Guidelines for Cholesterol Screening for “advocating change in the NCEP [National Cholesterol Education Program]/AHA [American Heart Association] guidelines.” Implicit in this claim are the beliefs that the NCEP guidelines represent the standard against which all cholesterol screening guidelines should be compared and that the ACP guidelines constitute a reaction to that standard. Neither belief is justified. Furthermore, the task force’s comments reflect misunderstandings about the purpose, content, and scientific foundation of the ACP guidelines.  The ACP produced new cholesterol guidelines as part of a periodic review of all of its guidelines. The updated guidelines and background paper focused on the questions addressed in the original background paper and guidelines: Which adults should undergo screening for lipoprotein disorders? What tests should be used initially? These questions are more narrowly focused than the range of issues addressed in the NCEP report,6 which considered not only the initial screening test but also the sequence of follow-up testing, the criteria for initiation of treatment, and the choice of interventions. Because the effectiveness of screening depends on the steps taken after the result of the screening test is obtained, the ACP implicitly considered some of these issues, but the additional steps were not the subject of recommendations. Thus, the task force mistakenly inferred that the ACP recommended against certain practices proposed by the NCEP (eg, measuring lipoprotein levels in patients with elevated total cholesterol levels) that were not explicitly addressed because they fell outside of the purview of the guidelines. (March 18, 1997)