ACC/AHA 2018 Guideline on Management of Blood Cholesterol
newer medications, more personalized risk calculation
The AHA/ACC 2018 guideline on the management of blood cholesterol, endorsed by at least 10 other medical societies has been recently published in the Journal of the American College of Cardiology and copublished in the journal Circulation.
Since the 2013 ACC/AHA cholesterol guideline, newer cholesterol-lowering agents (nonstatin drugs) have been introduced and they include ezetimibe and PCSK9 inhibitors, and their use is limited mainly to secondary prevention in patients at very high-risk of new atherosclerotic cardiovascular disease (ASCVD) events. Most other patients with ASCVD are treated with statins alone. The new guideline recommends a stepped approach including statins, ezetimibe and PCSK9 inhibitors in patients with prior CVD at very high risk for another event.
Throughout these guidelines similar to the 2013 guidelines, consistent attention is given to a clinician-patient risk discussion for making shared decisions. However, most attention is given to reducing lifetime ASCVD risk through lifestyle therapies. The guidelines have 26 class I recommendations, 29 class IIa recommendations, 14 class IIb recommendations and three class III recommendations.
Four major categories of patients with different management needs for whom statins may be considered
1. Primary prevention: that is, no clinical ASCVD or diabetes but LDL-C 70 mg/dL or higher and 7.5% or greater 10-year risk by the calculator
2. No clinical ASCVD but with diabetes and LDL-C of 70 mg/dL or greater
3. Secondary prevention: that is, clinical ASCVD without heart failure
4. Severe primary hypercholesterolemia (LDL-C ≥190 mg/dL), often called Familial Hypercholesterolemia (FH)
High, Moderate, and Low-Intensity Statin Therapy
Top 10 Take-Home Messages
1. In all individuals, emphasize a heart-healthy lifestyle across the life course
A healthy lifestyle reduces atherosclerotic cardiovascular disease (ASCVD) risk at all ages. In younger individuals, healthy lifestyle can reduce development of risk factors and is the foundation of ASCVD risk reduction.
In young adults 20 to 39 years of age, an assessment of lifetime risk facilitates the clinician-patient risk discussion and emphasizes intensive lifestyle efforts. In all age groups, lifestyle therapy is the primary intervention for metabolic syndrome.
2. In patients with clinical ASCVD, reduce low-density lipoprotein cholesterol (LDL-C) with high intensity statin therapy or maximally tolerated statin therapy
The more LDL-C is reduced on statin therapy, the greater will be subsequent risk reduction. Use a maximally tolerated statin to lower LDL-C levels by ≥50%.
3. In very high-risk ASCVD, use a LDL-C threshold of 70 mg/dL (1.8 mmol/L) to consider addition of nonstatins to statin therapy. Very high-risk includes a history of multiple major ASCVD events or 1 major ASCVD event and multiple high-risk conditions
- Very high-risk includes a history of multiple major ASCVD events or 1 major ASCVD event and multiple high-risk conditions. In very high-risk ASCVD patients, it is reasonable to add ezetimibe to maximally tolerated statin therapy when the LDL-C level remains ≥70 mg/dL (≥1.8 mmol/L).
- In patients at very high risk whose LDL-C level remains ≥70 mg/dL (≥1.8 mmol/L) on maximally tolerated statin and ezetimibe therapy, adding a PCSK9 inhibitor is reasonable, although the long-term safety (>3 years) is uncertain and cost effectiveness is low at mid-2018 list prices.
4. In patients with severe primary hypercholesterolemia (LDL-C level ≥190 mg/dL [≥4.9 mmol/L]), without calculating 10-year ASCVD risk, begin high-intensity statin therapy without calculating 10- year ASCVD risk
If the LDL-C level remains ≥100 mg/dL (≥2.6 mmol/L), adding ezetimibe is reasonable. If the LDL-C level on statin plus ezetimibe remains ≥100 mg/dL (≥2.6 mmol/L) and the patient has multiple factors that increase subsequent risk of ASCVD events, a PCSK9 inhibitor may be considered, although the long-term safety (>3 years) is uncertain and economic value is low at mid2018 list prices.
5. In patients 40 to 75 years of age with diabetes mellitus and LDL-C ≥70 mg/dL (≥1.8 mmol/L), start moderate-intensity statin therapy without calculating 10-year ASCVD risk
In patients with diabetes mellitus at higher risk, especially those with multiple risk factors or those 50 to 75 years of age, it is reasonable to use a high-intensity statin to reduce the LDL-C level by ≥50%.
6. In adults 40 to 75 years of age evaluated for primary ASCVD prevention, have a clinician-patient risk discussion before starting statin therapy
- Risk discussion should include a review of major risk factors (e.g., cigarette smoking, elevated blood pressure, LDL-C, hemoglobin A1C [if indicated], and calculated 10-year risk of ASCVD)
- The presence of risk-enhancing factors
- The potential benefits of lifestyle and statin therapies
- The potential for adverse effects and drug–drug interactions; consideration of costs of statin therapy; and patient preferences and values in shared decision making
7. In adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dL (≥1.8 mmol/L), at a 10-year ASCVD risk of ≥7.5%, start a moderate-intensity statin if a discussion of treatment options favors statin therapy
Risk-enhancing factors favor statin therapy. If risk status is uncertain, consider using coronary artery calcium (CAC) to improve specificity. If statins are indicated, reduce LDL-C levels by ≥30%, and if 10-year risk is ≥20%, reduce LDL-C levels by ≥50%.
8. In adults 40 to 75 years of age without diabetes mellitus and 10-year risk of 7.5% to 19.9% (intermediate risk), risk-enhancing factors favor initiation of statin therapy
- Risk enhancing factors include:-
- family history of premature ASCVD
- persistently elevated LDL-C levels≥160 mg/dL (≥4.1 mmol/L)
- metabolic syndrome
- chronic kidney disease
- history of preeclampsia or premature menopause (age < 40 yrs)
- chronic inflammatory disorders (e.g., rheumatoid arthritis, psoriasis, or chronic HIV)
- high-risk ethnic groups (e.g., South Asian)
- persistent elevations of triglycerides ≥175 mg/dL (≥1.97 mmol/L); and, if measured in selected individuals, apolipoprotein B ≥130 mg/dL, high-sensitivity C-reactive protein ≥2.0 mg/L, ankle-brachial index <0.9 and lipoprotein (a) ≥50 mg/dL or 125 nmol/L, especially at higher values of lipoprotein (a)
- Risk-enhancing factors may favor statin therapy in patients at 10-year risk of 5-7.5% (borderline risk).
9. In adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dL- 189 mg/dL (≥1.8-4.9 mmol/L), at a 10-year ASCVD risk of ≥7.5% to 19.9%, if a decision about statin therapy is uncertain, consider measuring CAC
- If CAC is zero, treatment with statin therapy may be withheld or delayed, except in cigarette smokers, those with diabetes mellitus, and those with a strong family history of premature ASCVD.
- A CAC score of 1 to 99 favors statin therapy, especially in those ≥55 years of age.
- For any patient, if the CAC score is ≥100 Agatston units or ≥75th percentile, statin therapy is indicated unless otherwise deferred by the outcome of clinician–patient risk discussion.
10. Assess adherence and percentage response to LDL-C-lowering medications and lifestyle changes with repeat lipid measurement 4 to 12 weeks after statin initiation or dose adjustment, repeated every 3 to 12 months as needed
Define responses to lifestyle and statin therapy by percentage reductions in LDL-C levels compared with baseline. In ASCVD patients at very high-risk, triggers for adding nonstatin drug therapy are defined by threshold LDL-C levels ≥70 mg/dL (≥1.8 mmol/L) on maximal statin therapy.
The American College of Cardiology is a 52,000-member medical society that is the professional home for the entire cardiovascular care team. The mission of the College is to transform cardiovascular care and to improve heart health. The American Heart Association is a non-profit organization in the United States that fosters appropriate cardiac care in an effort to reduce disability and deaths caused by cardiovascular disease and stroke.
Note: This list is a brief compilation of some of the key recommendations included in the Guideline and is not exhaustive and does not constitute medical advice. Kindly refer to the original publication here: https://pxmd.co/MHv9B