Applied Evidence

Translating AHA/ACC cholesterol guidelines into meaningful risk reduction

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Fasting vs nonfasting lipid profiles. In contrast to previous guidelines,2,8 which used fasting lipid profiles, nonfasting lipid profiles are now recommended for establishing a baseline LDL-C level and for ASCVD risk estimation for most patients—as long as the triglycerides (TG) level is < 400 mg/dL. When the calculated LDL-C level is < 70 mg/dL using the standard Friedewald formula, obtaining a direct LDL-C or a modified LDL-C estimate9 is deemed reasonable to improve accuracy. (The modified LDL-C can be estimated using The Johns Hopkins Hospital’s free “LDL Cholesterol Calculator” [www.hopkinsmedicine.org/apps/all-apps/ldl-cholesterol-calculator]).

A fasting lipid profile is still preferred for patients who have a family history of a lipid disorder. The definition of hypertriglyceridemia has been revised from a fasting TG level ≥ 150 mg/dL to a nonfasting or fasting TG level ≥ 175 mg/dL.1

Nonstatin add-on therapy. The new guideline supports the addition of nonstatin therapies to maximally tolerated statin therapy in patients who have established ASCVD or a primary LDL-C elevation ≥ 190 mg/dL when (1) the LDL-C level has not been reduced by the expected percentage (≥ 50% for high-intensity statin therapy) or (2) explicit LDL-C level thresholds have been met.1

Although measurement of the coronary artery calcium score by CT is generally not covered by insurance, its cost ($50-$450) nationwide makes it accessible.

The principal 2 groups of recommended nonstatins for which there is randomized, controlled trial evidence of cardiovascular benefit are (1) the cholesterol-absorbing agent ezetimibe10 and (2) the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors evolocumab11 and alirocumab.12

AAFP’s guarded positions on the 2013 and 2018 guidelines

The American Academy of Family Physicians (AAFP) welcomed the patient-centered and outcome-oriented aspects of the 2013 ACC/AHA guidelines, endorsing them with 3 qualifications.13

  1. Many of the recommendations were based on expert opinion, not rigorous research results—in particular, not on the findings of randomized controlled trials (although key points are based on high-quality evidence).
  2. There were conflicts of interest disclosed for 15 members of the guidelines panel, including a vice chair.
  3. Validation of the PCE risk estimation tool was lacking.

Continue to: AAFP announced...

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