Spotlight From the American Society for Preventive Cardiology on Key Features of the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guidelines on the Management of Blood Cholesterol

Nathan D. Wong; Ezra A. Amsterdam; Christie Ballantyne; Amit Khera; Khurram Nasir; Peter P. Toth

Disclosures

Am J Cardiovasc Drugs. 2020;20(1):1-9. 

In This Article

Abstract and Introduction

Abstract

The 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol retains focus on recommendations for statin treatment in the original four statin-eligible groups [those with atherosclerotic cardiovascular disease (ASCVD), diabetes, low-density lipoprotein cholesterol (LDL-C) ≥ 190 mg/dL, and higher risk primary prevention] without the use of treatment initiation or target LDL-C levels from the earlier 2013 American College of Cardiology/American Heart Association (ACC/AHA) guideline, but has several new features. First, patients with primary prevention are divided into those who are at low (< 5%), borderline (5% to < 7.5%), intermediate (7.5% to < 20%), and high (≥ 20%) risk based on the ASCVD risk estimator. Moreover, the new guideline goes further to consider a wider range of factors [now called "risk enhancers"—premature family history of ASCVD, persistently high LDL-C, chronic kidney disease (CKD), metabolic syndrome, conditions specific to women, inflammatory diseases, and high-risk ethnicities] that can be used to better inform the treatment decision. Moreover, more detailed recommendations on how the results of coronary calcium scanning can be used to inform the treatment decision are provided, including how it may be used to "de-risk" certain patients for delaying or avoiding the use of statin therapy. There are also specific sections for cholesterol management in other patient subgroups including women, children, certain ethnic groups, those with CKD, chronic inflammatory disorders and HIV, as well as discussion on the management of hypertriglyceridemia. Importantly, for persons with known ASCVD, a distinction is made for those who are at "very high risk" based on having had two major ASCVD events or one major event and two or more other high risk conditions, such as diabetes or other major risk factors, or bypass surgery or percutaneous intervention. Finally, the concept of a threshold LDL-C for initiating a non-statin therapy (after considering highest tolerated statin dosage) is provided, with ezetimibe recommended as the key non-statin to be added if the LDL-C still remains ≥ 70 mg/dL for all ASCVD patients, and in those who are at "very high risk", further consideration for using a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor. While the new guideline does have greater detail (and arguably, complexity), the refinements provide a strategy for guiding the clinician to target both statin and non-statin therapy to those most likely to derive benefit.

Introduction

The most recent, 2018, AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol[1] is a substantial collaborative effort among key societies, including authorship from the American Society for Preventive Cardiology (ASPC). While it still retains focus on recommendations for statin treatment in the original four statin-eligible groups from the earlier 2013 American College of Cardiology/American Heart Association (ACC/AHA) guideline,[2] the new guideline goes further to consider a wider range of factors (now called "risk enhancers") that can be used to better inform the treatment decision, and addresses implications of treatment for other patient subgroups including women, children, certain ethnic groups, those with chronic kidney disease (CKD), chronic inflammatory disorders and HIV, as well as discussion on the management of hypertriglyceridemia. Given that its foundations [e.g., focus on statin therapy recommendations and absence of specific initiation or target levels of low-density lipoprotein cholesterol (LDL-C)] are not substantially different from the 2013 release, it has attracted far less attention and controversy compared to its predecessor.

At the recent American College of Cardiology Scientific Sessions in March 2019, the revised Primary Prevention of Cardiovascular Disease Guidelines[3] were also presented. These were the first such release focusing on primary prevention in more than a decade and were intended to be a compendium of the recent cholesterol and blood pressure guidelines with an update on lifestyle management, and this time also included guidelines for smoking cessation and updated aspirin guidelines to promote disease prevention as a cornerstone of cardiovascular medicine. They included the primary prevention part of the 2018 cholesterol guidelines release. Central to the Primary Prevention of Cardiovascular Disease Guidelines and relevant to cholesterol management is the strong recommendation for patient-centered approaches for comprehensive atherosclerotic cardiovascular disease (ASCVD) prevention, including a team-based approach for control of risk factors for ASCVD (class I recommendation), shared decision making to guide discussions about the best strategies to reduce ASCVD risk (class I recommendation), and use of social determinants of health to inform optimal implementation of treatment recommendations for prevention of ASCVD (class I recommendation).

There are some key similarities and differences between the 2013 and 2018 guidelines. Importantly, the 2018 guidelines have kept the original four key statin eligible groups: those with (1) documented ASCVD, (2) LDL-C ≥ 190 mg/dL, (3) diabetes, and (4) increased ASCVD risk requiring primary prevention. Within these groups, however, there are further refinements (and arguably, greater complexity) as to the specific recommended therapy needing explanation. Moreover, the clinician/patient discussion, which was a hallmark of the 2013 guidelines, especially with the use of the risk calculator, is even more important with the introduction of additional "risk enhancers" as well as a greater role for use of results from coronary calcium screening, not only for informing the decision to treat, but also, for the first time, identifying patients for whom treatment can perhaps be withheld or delayed. Finally, for those with known ASCVD, criteria are now provided for categorization into those at "very high risk" and "not at very high risk" with treatment algorithms and LDL-C thresholds provided for initiation non-statin therapy for each group.

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