The American Heart Association (AHA) and the American College of Cardiology (ACC) have published a new guideline with recommendations for cholesterol management across all ages and for reducing the risk and/or burden of atherosclerotic cardiovascular disease (ASCVD). The guideline synopsis was published in the Annals of Internal Medicine.
An expert panel was convened by the AHA/ACC to perform a systematic literature review and meta-analyses of randomized controlled trials that reported cardiovascular outcomes. Independent researchers free from industry-related conflicts of interest reviewed evidence regarding the risks and benefits for the addition of nonstatin therapies to statins vs statin monotherapy in individuals who have or are at risk for ASCVD.
Maintaining a healthy lifestyle across the lifespan was the first recommendation by the committee, as this recommendation can reduce the risk for ASCVD at all ages. Even in younger individuals, healthy dietary patterns and an active lifestyle may be the best strategy for preventing risk factors for ASCVD and subsequently inhibit the need for statins later in life. Patients with ASCVD are also recommended to start statins at maximally tolerated or high-intensity doses to reduce low-density lipoprotein cholesterol (LDL-C). An obtainable goal with these therapies is the reduction of LDL-C by a mean of ≥50%.
Patients at very high risk for ASCVD (ie, individuals with a history of multiple major ASCVD events or one major ASCVD event and other high-risk comorbidities) are recommended to use nonstatin therapies plus statins. The panel proposed an LDL-C threshold of 1.8 mmol/L (70 mg/dL) for the addition of nonstatin therapies, including either ezetimibe or proprotein convertase subtilisin/kexin type 9 inhibitor therapies.
The initiation of maximally tolerated statin therapy may be necessary for reducing LDL-C levels to a lower risk range in patients with primary, severe hypercholesterolemia (LDL-C level ≥4.9 mmol/L [≥190 mg/dL]). The guideline also recommended starting moderate-intensity statins in adults age 40 to 75 who also have diabetes mellitus and an LDL-C of ≥1.8 mmol/L (70 mg/dL).
Other topics discussed in the guideline included recommendations for ensuring statin safety and strategies for risk stratification for primary prevention.
“For persons at increased risk for ASCVD who belong to groups shown to benefit from cholesterol-lowering drug therapy added to a heart-healthy lifestyle, as well as to those persons who present with ASCVD,” the panel wrote, “these guidelines represent an evidence-based approach to ASCVD preventive efforts.”
Grundy SM, Stone NJ; Guideline Writing Committee for the 2018 Cholesterol Guidelines. 2018 Cholesterol Clinical Practice Guidelines: Synopsis of the 2018 American Heart Association/American College of Cardiology/Multisociety Cholesterol Guideline [published May 27, 2019]. Ann Intern Med. doi:10.7326/M19-0365