2018 American College of Cardiology/American Heart Association Cholesterol Clinical Practice Guidelines

2018 American College of Cardiology/American Heart Association Cholesterol Clinical Practice Guidelines

2018 American College of Cardiology/American Heart Association Cholesterol Clinical Practice Guidelines

 By Heather Nelson Cortes, PhD, Mary R Dicklin, PhD and Kevin C Maki, PhD

 

The American College of Cardiology (ACC) and the American Heart Association (AHA) recently released their 2018 Guideline on the Management of Blood Cholesterol during the 2018 AHA meeting in Chicago, IL and simultaneously in Circulation1 and the Journal of the American College of Cardiology.1 The authors listed the top 10 take-home messages from the guidelines (see below, taken from the publication):

  1. In all individuals, emphasize a heart-healthy lifestyle across the life course.
  2. In patients with clinical atherosclerotic cardiovascular disease (ASCVD), reduce low-density lipoprotein cholesterol (LDL-C) with high-intensity statin therapy or maximally tolerated statin therapy.
  3. In very high-risk ASCVD, use a LDL-C threshold of 70 mg/dL (1.8mmol/L) to consider addition of non-statins to statin therapy.
  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.
  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.
  6. In adults 40 to 75 years of age evaluated for primary ASCVD, have a clinician-patient risk discussion before starting statin therapy.
  7. In adults 40 to 75 years of age without diabetes mellitus and with LDL-C ≥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.
  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 (see No. 7).
  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 coronary artery calcium (CAC).
  10. Assess adherence and percentage response to LDL-C-lowering medications and lifestyle changes with repeat lipid measurement 4 to 12 weeks after statin initiations or dose adjustment, repeated every 3 to 12 months as needed.

 

Comment: The previous ACC/AHA guidelines released in 2013 sparked a considerable amount of debate.2,3  Major areas of controversy at that time included the use of a new risk calculator for assessing 10-year ASCVD, and, notably, abandoning the use of lipid goals.3 Those guidelines were exceedingly statin-centric, and did not provide guidance for managing cholesterol with non-statin lipid-altering drugs.  Another set of national recommendations released shortly after the 2013 ACC/AHA guidelines, the National Lipid Association (NLA) recommendations for the patient-centered management of dyslipidemia, employed a more traditional approach of titrating lipid-lowering therapy to achieve patient-specific LDL-C and non-high-density lipoprotein cholesterol (non-HDL-C) goals.4  The NLA also recommended combination of statin and non-statin drugs to achieve atherogenic cholesterol goals when maximum tolerated statin therapy was inadequate.  Both sets of recommendations emphasized lifestyle management, and the importance of patient-clinician discussions in managing elevated cholesterol.

 

Noteworthy changes in the new ACC/AHA guidelines include goals by using percentage reductions to monitor adequacy of response to LDL-C-lowering therapy.  They also lower the CAC score for enhanced risk, and include lipoprotein(a) as a risk-enhancing factor that can be considered when the decision to use statin therapy is otherwise uncertain.1  The new ACC/AHA guidelines recommend that a CAC score of 1-99 favors statin use (especially after age 55 years), and that a CAC score of 100+ and/or ≥75th percentile is an indication to initiate statin therapy.  If measured in selected individuals, a lipoprotein(a) level of >50 mg/dL or >125 nmol/L indicates enhanced risk.  The new guidelines also recommend using non-statin drugs, specifically ezetimibe or a proprotein convertase subtilisin kexin type 9 inhibitor, but suggest that their use is limited mainly to secondary prevention in patients at very high-risk of new ASCVD events.

 

The new ACC/AHA guidelines close much of the gap between the 2013 guidelines and the NLA recommendations on issues that previously were either handled differently or had been unaddressed by the ACC/AHA.  We expect that these new guidelines will be readily incorporated into clinical practice and improve patient outcomes.

 

References:

  1. Grundy SM, Stone NJ, Bailey AL, 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. 2018; Epub ahead of print and J Am Coll Cardiol. 2018; Epub ahead of print.
  2. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guidelines on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardio. 2014;63 (Pt B):2889-2934.
  3. Phillips E, Sasseen JJ. Current controversies with recent cholesterol treatment guidelines. J Pharm Pract. 2016;29:15-25.
  4. Jacobson TA, Ito MK, Maki KC, et al. National Lipid Association recommendations for patient-centered management of dyslipidemia: part 1 – executive summary. J Clin Lipidol. 2014;8:473-488.

 

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