Cholesterol guidelines updated with newer medications, more personalized risk calculation
CHICAGO — New cholesterol guidelines from the American Heart Association, American College of Cardiology and 10 other societies recommend a stepped approach including statins, ezetimibe and PCSK9 inhibitors in patients with prior CVD at very high risk for another event.
“The most intensive LDL lowering is reserved for those patients at the very highest risk,” Neil J. Stone, MD, the Robert Bonow, MD, professor of medicine and preventive medicine at Northwestern University Feinberg School of Medicine and vice chair of the writing committee, said during a press conference at the AHA Scientific Sessions, where the new guidelines were unveiled.
Personalized risk assessment, LDL targets
The new guidance also calls for more personalized risk assessments than outlined in the previous version, which was published in 2013.
Of note, an LDL target of < 70 mg/dL is recommended for certain high-risk patients. Targets had been eliminated in the 2013 guidelines.
“There is no ideal target for LDL in the general population, but in principle, lower is better,” AHA president Ivor Benjamin, MD, FAHA, director of the Cardiovascular Center at the Medical College of Wisconsin, said during the press conference.
The guidelines emphasize management of cholesterol on a case-by-case basis and encourage patient-provider discussions of risk before a decision on a treatment plan.
“As we move into an era where care is personalized, how we prevent and treat heart disease differs patient by patient,” Richard Kovacs, MD, FACC, the Q.E. and Sally Russell Professor of Cardiology at Indiana University School of Medicine, clinical director of the Krannert Institute of Cardiology and vice president of the ACC, said during the press conference. “These guidelines give us the tools we need to do that.”
The Pooled Cohort Equation from the 2013 guidelines remains as the recommended tool with which to estimate CVD risk.
“This is the most widely validated risk score in the contemporary U.S. population,” Stone said here. “The important point to remember is that the risk estimate should begin the risk discussion.”
10 take-home messages
The guidelines, written by Scott M. Grundy, MD, PhD, FAHA, director of the Center for Human Nutrition, chairman of the department of clinical nutrition and director of the Clinical and Translational Research Center at UT Southwestern Medical Center, and colleagues, feature 10 important take-home messages:
- A lifetime of heart-healthy lifestyle should be emphasized for all patients.
- Patients with clinical atherosclerotic CVD (ASCVD) should be prescribed a high-intensity statin or maximally tolerated statin therapy for LDL reduction.
- Patients with ASCVD at very high risk, defined as multiple CVD events or one CVD event and multiple high-risk characteristics, should be considered for nonstatin therapy if they cannot achieve an LDL target of < 70 mg/dL on statin therapy. Ezetimibe should be tried first; if the LDL target is still not achieved, after a cost discussion, a PCSK9 inhibitor may be considered.
- Patients with LDL 190 mg/dL or more should be prescribed high-intensity statin therapy regardless of risk; high-risk patients with diabetes should be prescribed high-intensity statin therapy with a goal of reducing LDL by at least 50%.
- Regarding adults aged 40 to 75 years being considered for statin therapy for primary prevention, a clinician-patient risk discussion should occur before commencing statin therapy. The discussion should include risk factors, risk-enhancing factors, potential benefits of lifestyle measures and statin therapy, potential for adverse events and drug-drug interactions, costs and patient preferences.
- In patients aged 40 to 75 years with diabetes and LDL at least 70 mg/dL, moderate-intensity statin therapy should be started regardless of 10-year ASCVD risk.
- For adults aged 40 to 75 years with LDL 70 mg/dL or higher, without diabetes and with 10-year ASCVD risk of at least 7.5%, a moderate-intensity statin regimen is recommended if the risk discussion favors it. If risk status is uncertain, coronary artery calcium scoring can be used to improve specificity. If statin therapy is prescribed, the goal should be LDL reduction of at least 30% (at least 50% if 10-year atherosclerotic CVD risk is 20% or more).
- For adults aged 40 to 75 years with LDL 70 mg/dL or higher, without diabetes and with 10-year ASCVD risk of 7.5% to 19.9%, risk-enhancing factors can be used to further refine whether statin therapy should be initiated. Risk-enhancing factors include family history of premature ASCVD, persistent LDL of at least 160 mg/dL, metabolic syndrome, chronic kidney disease, preeclampsia, premature menopause, chronic inflammatory disorders, belonging to a high-risk race or ethnicity, persistent elevated triglycerides (at least 175 mg/dL), and, if measured, elevated apolipoprotein B, elevated high-sensitivity C-reactive protein, ankle-brachial index < 0.9 and lipoprotein(a) 50 mg/dL or higher.
- For adults aged 40 to 75 years with LDL 70 mg/dL or higher, without diabetes and with 10-year ASCVD risk of 7.5% to 19.9%, if risk-enhancing factors do not produce a refined risk assessment, consider measuring CAC. Statin therapy should be initiated in patients with CAC score 100 Agatston units or more, should be considered in patients with CAC score 1 to 99 Agatston units and should not be initiated in patients with a CAC score of 0 unless they are current smokers, have diabetes or have a family history of premature atherosclerotic CVD.
“A CAC score of 0 means the 10-year event rates are likely to be below the range where statins provide a net benefit,” Stone said at the press conference.
- After initiation of lipid-lowering therapies, assess adherence and response to medication and lifestyle measures at 4 to 12 weeks, then every 3 to 12 months thereafter.
The guidelines have 26 class I recommendations, 29 class IIa recommendations, 14 class IIb recommendations and three class III recommendations, Sidney C. Smith Jr., MD, FAHA, FESC, FACP, MACC, professor of medicine at the University of North Carolina-Chapel Hill, past president of the AHA and the World Heart Federation and a member of the writing committee, said during the press conference.
“That is a lot to read, so I am telling people to know the class I and class III recommendations, then move on from there,” he said. “Understand that the guidelines are inclusive of the science we have learned in the last 5 years.”
The guidelines were simultaneously published in Circulation and the Journal of the American College of Cardiology. – by Erik Swain
Grundy SM, et al. 2018 AHA/ACC Cholesterol Clinical Practice Guidelines. Presented at: American Heart Association Scientific Sessions; Nov. 10-12, 2018; Chicago.
Disclosures: All members of the writing committee, Benjamin and Kovacs report no relevant financial disclosures. Please see the guidelines for a list of the reviewers’ relevant financial disclosures.