How is coronary artery atherosclerosis prevented?

Updated: Apr 09, 2021
  • Author: Sandy N Shah, DO, MBA, FACC, FACP, FACOI; Chief Editor: Yasmine S Ali, MD, MSCI, FACC, FACP  more...
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Answer

The goals of therapy should include arresting atherosclerosis or even reversing its progression. Large, multicenter randomized trials of various pharmacologic modalities have recently achieved great success in the treatment of patients with coronary artery atherosclerosis. In addition, addressing risk factors with lifestyle changes is an integral part of atherosclerosis prevention.

Therapy with lipid-lowering agents should be a component of multiple risk factor intervention and is indicated in primary prevention as an adjunct to diet therapy when the response to a diet restricted in saturated fat and cholesterol has been inadequate. Substantial evidence supports the use of statins in the secondary prevention of CAD, and the efficacy of statins has recently been extended to include primary prevention of CAD in patients with average cholesterol levels.

A separate study found that, compared with placebo or statin monotherapy, evacetrapib as monotherapy or in combination with statins increased HDL-C levels and decreased LDL-C levels. However, further investigation is warranted. [50]

A meta-analysis of nearly 5000 patients found that statins administered before invasive procedures significantly reduced the risk for postprocedural myocardial infarction. [51] The risk for MI was reduced after percutaneous coronary intervention and noncardiac surgical procedures, but not for coronary artery bypass grafting (CABG). Statins decreased the risk for atrial fibrillation following CABG.

Current guidelines recommend using statin therapy after CABG to keep LDL levels below 100 mg/dL. Results of the Clopidogrel After Surgery for Coronary Artery Disease (CASCADE) trial confirmed that this practice independently associated with improved graft patency, as demonstrated by coronary angiography and saphenous vein graft intravascular ultrasonography. performed 12 months postoperatively. However, LDL reduction to less than 70 mg/dL did not lead to further improvement in graft patency. [52]

Statin therapy is also safe and can improve liver tests while reducing cardiovascular morbidity in patients with mild- to moderately-abnormal liver test results that may be attributable to nonalcoholic fatty liver disease. [53]

In the United States, the most commonly used guidelines for cholesterol management are those from the NCEP Adult Treatment Panel (ATP). In high-risk persons, the recommended LDL-C goal is less than 100 mg/dL, but when risk is very high, an LDL-C goal of less than 70 mg/dL is a therapeutic option and a reasonable clinical strategy based on available clinical trial evidence. For moderately high-risk persons (≥2 risk factors and 10-y risk of 10-20%), the recommended LDL-C goal is less than 130 mg/dL, but an LDL-C goal of less than 100 mg/dL is a therapeutic option based on trial evidence.

Newer guidelines on the management of elevated blood cholesterol, released in late 2013 by the American Heart Association/American College of Cardiology (AHA/ACC), no longer specify LDL- and non-HDL-cholesterol targets for the primary and secondary prevention of atherosclerotic cardiovascular disease. [54, 55] The guidelines identify four groups of primary- and secondary-prevention patients in whom efforts should be focused to reduce cardiovascular disease events and recommend appropriate levels of statin therapy for these groups.

Treatment recommendations include the following :

  • In patients with atherosclerotic cardiovascular disease, or those with LDL cholesterol levels 190 mg/dL or higher (eg, due to familial hypercholesterolemia), and no contraindications, high-intensity statin therapy should be prescribed to achieve at least a 50% reduction in LDL cholesterol

  • In patients aged 40 to 75 years of age with diabetes, a moderate-intensity statin that lowers LDL cholesterol by 30% to 49% should be used; in those patients who also have a 10-year risk of atherosclerotic cardiovascular disease exceeding 7.5%, a high-intensity statin is a reasonable choice

  • In individuals aged 40 to 75 years without cardiovascular disease or diabetes but with a 10-year risk of clinical events >7.5% and an LDL-cholesterol level of 70-189 mg/dL, a moderate- or high-intensity statin should be used

A study applying the 2013 AHA/ACC cholesterol guidelines to data from the 2005–2010 National Health and Nutrition Examination Surveys (NHANES) estimated that an additional 12.8 million US adults would be eligible for statin therapy as compared with treatment based on the NCEP ATP III guidelines. [56, 57] About 10.4 million of these adults would be eligible to receive statins for primary prevention—primarily older people without cardiovascular disease, men more often than women, those with higher blood pressure, and those with lower LDL-C levels.

The 2013 AHA/ACC guidelines also recommend use of a revised calculator to estimate the risk of developing a first atherosclerotic cardiovascular disease (ASCVD) event, which is defined as one of the following, over a 10-year period, in a person who was initially free from ASCVD [21] :

  • Nonfatal myocardial infarction

  • Death from coronary heart disease

  • Stroke (fatal or nonfatal)

For patients 20-79 years of age who do not have existing clinical ASCVD, the guidelines recommend assessing clinical risk factors every 4-6 years. For patients with low 10-year risk (< 7.5%), the guidelines recommend assessing 30-year or lifetime risk in patients 20-59 years old.

Regardless of the patient’s age, clinicians should communicate risk data to the patient and refer to the AHA/ACC lifestyle guidelines, which cover diet and physical activity. For patients with elevated 10-year risk, clinicians should communicate risk data and refer to the AHA/ACC guidelines on blood cholesterol and obesity.


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