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Updated Lipid Management Guidelines

Treatment of dyslipidemia is the foundation of preventive cardiology. Reduction in low-density lipoprotein (LDL-C) reduces risk of atherosclerotic cardiovascular disease (ASCVD) events in both primary and secondary prevention.The American College of Cardiology, American Heart Association and other professional societies recently published an updated guideline on the management of blood cholesterol. The 2018 guideline emphasizes reducing risk of ASCVD through lipid management. It updates the 2013 guideline and emphasizes a more intensive approach based on recent controlled studies and expert consensus. The guideline uses the following definitions:

• Clinical ASCVD includes stroke, transient ischemic attack (TIA), coronary artery disease (CAD) with stable angina, acute coronary syndromes (ACS), coronary or other arterial revascularization, peripheral vascular disease with or without claudication, and aortic aneurysm.
• High-risk conditions are defined as age ≥65 years, heterozygous familial hypercholesterolemia (HeFH), prior coronary revascularization outside of the major ASCVD events, diabetes, hypertension, chronic kidney disease with estimated glomerular filtration rate of 15 to 59, current smoker, and LDL-C ≥100 mg/dl despite maximally tolerated statin therapy and ezetimibe.
• Very high risk for future ASCVD events includes a history of multiple major ASCVD events such as ACS within 12 months, myocardial infarction, ischemic stroke, peripheral arterial disease, previous revascularization or amputation, or one major event with multiple high-risk conditions.

Seven of the top recommendations of this guideline are summarized below:

1. Physicians should emphasize a lifelong heart-healthy lifestyle for individuals of all ages because it reduces ASCVD risk. In all age groups, lifestyle therapy is the primary intervention for metabolic syndrome. 
   
2. In patients with clinical ASCVD, low-density lipoprotein cholesterol (LDL-C) should be reduced by at least 50% with maximally tolerated statins to decrease ASCVD risk.
3. An LDL-C threshold of 70 mg/dl should be used for patients at very high-risk of ASCVC. Ezetimibe may be added to maximally tolerated statin therapy when LDL-C level remains ≥70 mg/dl. In patients at very high risk whose LDL-C level remains ≥70 mg/dl on maximally tolerated statin and ezetimibe therapy, it is reasonable to add a PCSK9 inhibitor. The long-term safety (>3 years) and economic value of PCSK9 inhibitors is uncertain. 
4. Moderate intensity statins should be started for patients 40 to 75 years of age with diabetes mellitus and an LDL-C level of ≥70 mg/dl. 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%.
5. In adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dl, at a 10-year ASCVD risk of ≥7.5%, a moderate-intensity statin should be considered to reduce LDL-C levels by ≥30%. If 10-year risk is ≥20%, the goal should be to reduce LDL-C levels by ≥50%. 
   
6. In adults 40 to 75 years of age without diabetes mellitus and 10-year risk of 5%-19.9%, 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; metabolic syndrome; chronic kidney disease; history of preeclampsia or premature menopause; chronic inflammatory disorders; high-risk ethnic groups; persistent elevations of triglycerides ≥175 mg/dl; apolipoprotein B ≥130 mg/dl, high-sensitivity C-reactive protein ≥2.0 mg/L, ABI <0.9, and lipoprotein(a) ≥50 mg/dl. 
    
7. Adherence and percentage response to LDL-C–lowering medications and lifestyle changes should be monitored with repeat lipid measurement 4 to 12 weeks after statin initiation or dose adjustment and then every 3 to 12 months as needed. Responses to lifestyle and statin therapy are defined by the percentage reductions in LDL-C levels compared with baseline.

References

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. [Published online ahead of print November 10, 2018]. Circulation. doi:10.1161/CIR.0000000000000625.

Lloyd-Jones DM, et al., Special Report on Use of Risk Assessment Tools to Guide Decision-Making in the Primary Prevention of ASCVD. J Am Coll Cardiol 2018;Nov 10:[Epub ahead of print]).