Cholesterol Management Guidelines

CHOLESTEROL MANAGEMENT GUIDELINES
SECONDARY PREVENTION IN PATIENTS WITH ASCVD
                                                                                                                                           
                                                    Clinical ASCVD1                                                    
                                                                                                                                           
                                                                                                                                       
                    ASCVD not at very high-risk     Healthy lifestyle     ASCVD at very high-risk3            
                                       
                                                                                                                                           
                                                                                                                                           
                                                                                                                               
            Age ≤75yrs                     Age >75yrs                                   High-intensity or maximal statin            
                                                                                                                                           
                                                                                                                               
    High-intensity statin2
(Goal: reduce LDL-C by ≥50%)
    Initiate moderate- or high-intensity statin or continue high-intensity statin                     If on maximal statin and LDL-C ≥70mg/dL, can
add ezetimibe. If PCSK9-I is considered, add ezetimibe to maximal statin first before adding
   
                                                                                                                                           
                                                                                                                                   
    If on maximal statin and LDL-C ≥70mg/dL, can add ezetimibe                                                     If on clinically judged maximal LDL-C lowering
therapy and LDL-C ≥70mg/dL or non-HDL-C ≥100mg/dL, can add PCSK9-I
   
                                                                                                                                           
PRIMARY PREVENTION OF ASCVD
                                                                                                                                           
               

Assess ASCVD risk in each age group

Emphasize adherence to healthy lifestyle

                 

LDL-C ≥190mg/dL

No risk assessment; high-intensity statin4

   
                     
                                                                                                                                           
                                                                                         

Diabetes and age 40–75yrs

• No risk assessment; moderate-intensity statin

• Risk assessment to consider high-intensity statin5

   
                                                                                             
                                                                                                                                           
                                                                                                                                           
                                                                                                                           
   

Age 0–19yrs

Lifestyle to prevent or reduce ASCVD risk

Diagnosis of Familial Hypercholesterolemia: statin

 

Age 20–39yrs7

Estimate lifetime risk to encourage lifestyle to reduce ASCVD risk

Family history of premature ASCVD and LDL-C ≥160mg/dL: consider statin

 

Age 40–75yrs and LDL-C ≥70–<190mg/dL without diabetes

10-year ASCVD risk percent (PCE-calculated) begins risk discussion

 

Age >75yrs

Clinical assessment, risk discussion6

           
                                                                                                                                           
                                                                                                                                           
                                                                                                                           
                <5%
“Low risk”
            5–<7.5%
“Borderline risk”
            ≥7.5–<20%
“Intermediate risk”
            ≥20%
“High risk”
       
                                                                                                                                           
                                                                                                                           
           

Risk discussion6

Emphasize lifestyle to
reduce risk factors

   

Risk discussion6

If risk enhancers8 present, then risk discussion regarding moderate-intensity statin

   

Risk discussion6

If risk estimate + risk enhancers8 favor statin, initiate moderate-intensity statin to reduce LDL-C by 30–49%9

   

Risk discussion6

Initiate statin to reduce
LDL-C ≥50%

   
                                                                                                                                           
                                                                                                                                       
                                                           

If risk decision is uncertain:

Consider measuring CAC in selected adults:

CAC = 0: lowers risk; consider no statin, unless diabetes, family history of premature CHD, or cigarette smoking present

CAC = 1–99: favors statin (esp. after age 55)

CAC = 100+ and/or ≥75th percentile: initiate statin therapy

                   
                                                                                                                                           
STATIN THERAPY
High-Intensity Moderate-Intensity Low-Intensity

Daily dose lowers LDL-C by approx. ≥50%10

• atorvastatin 40–80mg

• rosuvastatin 20–40mg

Daily dose lowers LDL-C by approx. 30–49%10

• atorvastatin 10–20mg

• rosuvastatin 5–10mg

• simvastatin 20–40mg

• pravastatin 40–80mg

• lovastatin 40–80mg

• fluvastatin XL 80mg

• fluvastatin 40mg twice daily

• pitavastatin 1–4 mg

Daily dose lowers LDL-C by approx. <30%10

• simvastatin 10mg

• pravastatin 10–20mg

• lovastatin 20mg

• fluvastatin 20–40mg

NONSTATIN THERAPY

• Bile acid sequestrants: cholestyramine, colesevelam, colestipol

• Ezetimibe

• PCSK9 inhibitors: alirocumab, evolocumab

NOTES

Key: ACS = acute coronary syndrome; ASCVD = atherosclerotic cardiovascular disease; CAC = coronary artery calcium; CHD = coronary heart disease; CKD = chronic kidney disease; LDL-C = low-density lipoprotein cholesterol; HDL-C = high-density lipoprotein cholesterol; MI = myocardial infarction; PCE = pooled cohort equations; PCSK9-I = proprotein convertase subtilisin kexin type 9 inhibitor

Assess adherence and percentage response to LDL-C lowering medications and lifestyle changes with repeat lipid measurement 4–12wks after statin initiation or dose adjustment, repeated every 3–12mos as needed.

1 Clinical ASCVD consists of ACS, history of MI, stable or unstable angina, coronary other arterial revascularization, stroke, transient ischemic attack (TIA), or peripheral artery disease (PAD) including aortic aneurysm, all of atherosclerotic origin.

2 If high-intensity statin contraindicated or not tolerated, use moderate-intensity statin (Goal: reduce LDL-C by 30–49%).

3 Very high-risk includes a history of multiple major ASCVD events or 1 major ASCVD event and multiple high-risk conditions (eg, ≥65yrs, diabetes, hypertension, CKD [eGFR 15–59 mL/min/1.73m2], smoking, CHF, heterozygous familial hypercholesterolemia, prior CABG or PCI outside of major ASCVD event, persistently elevated LDL-C ≥100mg/dL).

4 If <50% reduction in LDL-C and/or LDL-C remains ≥100mg/dL on maximally tolerated statin, can add ezetimibe. If <50% reduction in LDL-C and fasting triglycerides ≤300mg/dL on statin and ezetimibe, may add bile acid sequestrant. If heterozygous FH and LDL-C remains ≥100mg/dL on statin and ezetimibe, may add PCSK9-I.

5 In adults with multiple ASCVD risk factors, initiate high-intensity statin to reduce LCL-C by ≥50%. In adults with 10-year ASCVD risk ≥20% who are on maximally tolerated statin therapy, may add ezetimibe to reduce LDL-C by ≥50%.

6 Risk discussion should include a review of major risk factors (eg, cigarette smoking, elevated blood pressure, LDL-C, hemoglobin A1C [if indicated], and calculated 10-yr risk of ASCVD); the presence of risk-enhancing factors (see note #8); 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 If diabetes mellitus present in this age group, consider diabetes-specific risk enhancers (eg, long duration [≥10yrs for T2DM or ≥20yrs for T1DM], albuminuria ≥30mcg albumin/mg creatinine, eGFR <60mL/min/1.73m2, retinopathy, neuropathy, ankle-brachial index [ABI] <0.9) to determine if initiation of statin therapy is appropriate.

8 ASCVD risk enhancers: family history of premature ASCVD, persistently elevated LDL-C ≥160mg/dL, CKD, metabolic syndrome, conditions specific to women (eg, preeclampsia, premature menopause), inflammatory disease (esp. rheumatoid arthritis, psoriasis, HIV), ethnicity (eg, South Asian ancestry). Lipid/biomarkers: persistently elevated triglycerides (≥175mg/dL). In selected individuals if measured: hs-CRP ≥2mg/L, Lp(a) >50mg/dL or >125nmol/L, apoB ≥130mg/dL, ABI <0.9.

9 In patients who would benefit from more aggressive LDL-C lowering and in whom high intensity statins are advisable but not acceptable or tolerated, it may be reasonable to add nonstatin drug therapy (eg, ezetimibe or bile acid sequestrant) to a moderate-intensity statin.

10 Percent reductions are estimates from data across large populations and reductions should be expected to vary in clinical practice.

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: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2018. doi: 10.1161/CIR.0000000000000625.

Created 1/2019