ACC/AHA lipid guidelines: Personalized care to prevent cardiovascular disease

Cara Reiter-Brennan; Albert D. Osei; S. M. Iftekhar Uddin; Olusola A. Orimoloye; Olufunmilayo H. Obisesan; Mohammadhassan Mirbolouk; Michael J. Blaha; Omar Dzaye

doi:10.3949/ccjm.87a.19078

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TABLE 1

Primary preventive therapy in different patient subgroups

Severe hypercholesterolemia

Initiate high-intensity statin therapy immediately, irrespective of 10-year risk of atherosclerotic cardiovascular disease (ASCVD)

Adding ezetimibe is reasonable if low-density lipoprotein cholesterol (LDL-C) is ≥ 190 mg/dL or there is less than 50% reduction in LDL-C levels with maximal tolerated statins

Consider adding a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor in patients with heterozygous familial hypercholesterolemia or with LDL-C ≥ 220 mg/dL with maximally tolerated statins and ezetimibe

Diabetes mellitus in adults

Irrespective of 10-year ASCVD risk, initiate moderate-intensity statin therapy immediately

Aim for reduction of LDL-C by at least 50%

Adults age 40–75 with LDL-C levels 70–189 mg/dL

Before starting statins, engage in clinician-patient risk discussion, evaluating risk factors, 10-year ASCVD risk, risk enhancers (Table 2), patient’s preference, costs, and adverse effects of statins

Use coronary artery calcium score to guide decision if risk is still unclear

Children and young adults

Assess risk factors in children age 0–19 years

Initiate statin therapy if patients have severely abnormal lipid profiles or clinical presentation of familial hypercholesterolemia and cannot be treated by 3 months lifestyle therapy

Ethnicity

Review racial and ethnic features that can influence ASCVD risk and intensity of treatment (Table 3)

Adults with chronic kidney disease

Starting moderate-intensity statin alone or in combination with ezetimibe can be useful

Adults with chronic inflammatory disorders and HIV

In adults age 40–75 with LDL-C 70–189 mg/dL with a 10-year ASCVD risk of over 5%, discuss moderate- or high-intensity statin therapy

Women

History of premature menopause (before age 40) or history of pregnancy-related disorders (hypertension, pre-eclampsia, gestational diabetes, small-for-gestational-age infants, and preterm deliveries) are risk-enhancing factors and should influence lifestyle and pharmacologic therapy decisions

Based on information in references 1 and 2.

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TABLE 2

Risk enhancers

Family history of premature atherosclerotic cardiovascular disease (in men age < 55 or in women age < 65)

Primary hypercholesterolemia
Low-density lipoprotein cholesterol 160–180 mg/dL
Non-high-density lipoprotein cholesterol 190–219 mg/dL

Metabolic syndrome: 3 or more of the following:
Increased waist circumference by ethnically appropriate cut points
Fasting triglyceride level > 150 mg/dL
High blood pressure
Elevated glucose
Low high-density lipoprotein cholesterol (< 40 mg/dL in men, < 50 mg/dL in women)
Chronic kidney disease (estimated glomerular filtration rate 15–59 mL/min/1.73 m²)

Chronic inflammatory conditions (eg, psoriasis, rheumatoid arthritis, lupus, human immunodeficiency virus infection, acquired immunodeficiency syndrome)

History of premature menopause (age < 40) and history of pregnancy-associated conditions that increase later risk of atherosclerotic cardiovascular disease such as preeclampsia

High-risk ethnicity or race (eg, South Asian)

Lipids or biomarkers associated with elevated risk
Persistently elevated hypertriglyceridemia (≥ 175 mg/dL nonfasting)
Elevated high-sensitivity C-reactive protein (≥ 2.0 mg/L)
Elevated lipoprotein (a) (≥ 50 mg/dL or ≥ 125 nmol/L) (relative indication for measurement: family history of premature atherosclerotic cardiovascular disease)
Elevated apolipoprotein B (≥ 130 mg/dL) (relative indication for measurement: triglycerides ≥ 200 mg/dL)
Ankle-brachial index < 0.9

Reprinted from 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: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019; 73(24):3168–3209. doi:10.1016/j.jacc.2018.11.002, with permission from Elsevier.

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TABLE 3

Racial and ethnic differences in atherosclerotic cardiovascular disease risk and coronary artery calcium scores

	Asian	Hispanic and Latino	Black, Native American, and Alaskan
ASCVD risk	South Asians^a have higher ASCVD risk than East Asians^b	Individuals from Puerto Rico have the highest ASCVD risk¹⁵ CVD mortality is higher in Hispanics than whites	Increased ASCVD risk¹⁴ Greater rates of CHD events compared with non-Hispanic white populations¹⁷
CAC score	South Asian men have similar CAC burden to non-Hispanic white men, but higher CAC compared with blacks and Latinos¹⁸ South Asian women have similar CAC scores compared with other ethnic and racial groups¹⁸	Lower CAC burden compared with Asian-Americans and non-Hispanic whites¹⁶	Lower CAC scores compared with whites and Hispanics¹⁶

↵a Individuals from Bangladesh, India, Nepal, Pakistan, and Sri Lanka make up most of the South Asian group.
↵b Individuals from Japan, Korea, and China make up most of of the East Asian group.
ASCVD = atherosclerotic cardiovascular disease; CAC = coronary artery calcium; CHD = coronary heart disease; CVD = cardiovascular disease

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TABLE 4

Key points on secondary prevention^a

Patient subgroup	Guideline recommendation
At very high risk^b	If low-density lipoprotein cholesterol (LDL- C) levels are ≥ 70 mg/dL with the maximal tolerated statin therapy, it is reasonable to add ezetimibe If LDL-C level is ≥ 70 mg/dL on maximal tolerated statin and ezetimibe, it is reasonable to add a PCSK9 inhibitor
Not at very high risk
Age ≤ 75	Goal is LDL-C reduction by 50% Use moderate-intensity statins if high- intensity statins are not tolerated If LDL-C ≥ 70 mg/dL on high-intensity statins, it is reasonable to add ezetimibe
Age > 75	Starting or continuing either moderate- or high-intensity statins is reasonable

↵a Secondary prevention refers to patients with clinical atherosclerotic cardiovascular disease (ASCVD), ie, those with a history of acute coronary syndrome, myocardial infarction, stable or unstable angina, arterial revascularization, stroke, transient ischemic attack, or peripheral artery disease.
↵b Very high risk includes a history of multiple major ASCVD events or 1 major ASCVD event and multiple high-risk conditions (age ≥ 65, heterozygous familial hypercholesterolemia, history of coronary artery bypass surgery or percutaneous coronary intervention, diabetes mellitus, hypertension, chronic kidney disease, current smoking, persistently elevated LDL-C, or history of heart failure).
Based on information in reference 1.