Article

A practical approach to the cholesterol guidelines and ASCVD prevention

Leslie Cho, MD
Cleveland Clinic Journal of Medicine May 2020, 87 (5 suppl 1) 15-20; DOI: https://doi.org/10.3949/ccjm.87.s1.02

Article Figures & Data

Figures

  • Figure 1
    Figure 1

    Primary prevention for atherosclerotic cardiovascular disease (ASCVD).

    LDL-C = low-density lipoprotein cholesterol

    Source: Data from reference 4.

  • Figure 2
    Figure 2

    Secondary prevention for atherosclerotic cardiovascular disease (ASCVD).

    HDL-C = high-density lipoprotein cholesterol; LDL-C = low-density lipoprotein cholesterol; PCKS9i = proprotein convertase subtilisin-kexin type 9 inhibitors; RCT = randomized controlled trial

    Source: Data from reference 4.

Tables

  • TABLE 1

    Key updates (in bold) to the cholesterol guidelines

    Topic20132018
    LifestyleCornerstone of ASCVD and preventionCornerstone of ASCVD and prevention
    First-line drugs for ASCVD risk reductionStatinsStatins
    Clinician-patient risk discussionIntroducedEmphasized before beginning statin
    Risk assessment in primary preventionStarts with PCE risk estimationStarts with PCE risk estimation
    Tailoring treatmentSome biomarkers and noninvasive testsExtensive list of risk enhancers
    Intermediate risk patientsNo recommendation for additional testingConsider CAC scoring and risk enhancers
    Nonstatin agents in secondary preventionNoneEzetimib (Zetia)
    PCSK9 inhibitors

    • ASCVD = atherosclerotic cardiovascular disease; CAC = coronary artery calcium; PCE = Pooled Cohort Equation; PCSK9 = proprotein convertase subtilisin-kexin type 9

      Source: Data from references 3 and 4.

  • TABLE 2

    Risk-enhancing factors for ASCVD

    FactorFindings
    Family history premature ASCVDMales: age < 55
    Females: age < 65
    Primary hypercholesterolemiaLDL-C: 160–189 mg/dL (4.1–4.8 mmol/L)
    Non-HDL-C: 190–219 mg/dL (4.9–5.6 mmol/L)
    Metabolic syndrome (3 or more)Waist circumference: increased
    Triglycerides: > 175 mg/dL
    Low HDL-C: < 40 mg/dL, men; < 50 mg/dL, women
    Elevated blood pressure
    Elevated glucose
    Specific to womenPremature menopause (before 40)
    Preeclampsia
    Chronic kidney diseaseeGFR: 15–59 mL/min/1.73 m2 with or without albuminuria
    Not treated with dialysis or transplant
    Chronic inflammatory conditionsPsoriasis, rheumatoid arthritis, HIV/AIDS
    High-risk ethnicitySouth Asian
    Lipids/biomarkershs-CRP: ≥ 2.0 mg/L
    Lp(a): ≥ 50 mg/dL (≥ 125 nmol/L)
    apoB: ≥ 130 mg/dL
    ABI: < 0.9

    • ABI = ankle-brachial index; apoB = apolipoprotein B; ASCVD = atherosclerotic cardiovascular disease; eGFR = estimated glomerular filtration rate; HDL-C = high-density lipoprotein cholesterol; hs-CRP = high-sensitive C-reactive protein; LDL-C = low-density lipoprotein cholesterol; Lp(a) = lipoprotein(a)

  • TABLE 3

    Nonstatin therapy for reduction of LDL-C

    DrugDoseAverage LDL-C reduction
    Ezetimibe10 mg, daily18% monotherapy 25% combined with statin
    Alirocumab (Praluent)75 mg SC, every 2 weeks
    150 mg SC, every 2 weeks    		45%
    58%
    Evolocumab (Repatha)140 mg SC, every 2 weeks
    420 mg SC, every 4 weeks    		64%
    58%

    • LDL-C = low-density lipoprotein cholesterol; SC = subcutaneously

  • TABLE 4

    Statin therapy for reduction of LDL-C

    DrugIntensity of LDL-C reduction
    High (> 50%)Moderate (30%–49%)Low (< 30%)
    Atorvastatin (Lipitor)40 mg/80 mg, daily10 mg/20 mg, daily
    Rosuvastatin (Crestor)20 mg/40 mg, daily5 mg/10 mg, daily
    Simvastatin (Zocor)20 mg/40 mg, daily10 mg, daily
    Pravastatin (Pravachol)40 mg/80 mg, daily10 mg/20 mg, daily
    Pitavastatin (Livalo)1 mg to 4 mg, daily
    Lovastatin (Mevacor, Altoprev)40 mg/80 mg, daily20 mg, daily
    Fluvastatin XL (Lescol XL)80 mg, daily
    Fluvastatin (Lescol)40 mg, twice daily20 mg/40 mg, daily

    • LDL-C = low-density lipoprotein cholesterol

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