Hyperlipidemia management: A calibrated approach
Gauge the level of LDL cholesterol and assess risk-enhancing factors for ASCVD—thus setting the table for primary and secondary prevention with medical therapy.
PRACTICE RECOMMENDATIONS
› Use an alternative to the Friedewald equation, such as the Martin–Hopkins equation, to estimate the low-density lipoprotein cholesterol (LDL-C) value; order direct measurement of LDL-C; or calculate non–high-density lipoprotein cholesterol to assess the risk for atherosclerotic cardiovascular disease (ASCVD) in patients who have a low LDL-C or a high triglycerides level. C
› Consider the impact of ASCVD risk-enhancing factors and coronary artery calcium scoring in making a recommendation to begin lipid-lowering therapy in intermediate-risk patients. C
› Add ezetimibe if a statin does not sufficiently lower LDL-C or if a patient cannot tolerate an adequate dosage of the statin. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
In adults at borderline risk (5% to < 7.5% 10-year ASCVD risk) or intermediate risk (≥ 7.5% to < 20% 10-year ASCVD risk), consider risk-enhancing factors to better inform your recommendation for preventive interventions. In these 2 groups, the presence of risk-enhancing factors might justify moderate-intensity statin therapy (TABLE 24).
If your decision regarding preventive intervention remains uncertain, measuring CAC might further guide your discussion with the patient.4 When the CAC score is:
- 0 Agatston units and higher-risk conditions (eg, diabetes, family history of premature coronary artery disease, smoking) are absent, statin therapy can be withheld; reassess ASCVD risk in 5 to 10 years.
- 1-99 Agatston units, statin therapy can be started, especially for patients ≥ 55 years of age.
- ≥ 100 Agatston units or ≥ 75th percentile, statin therapy is indicated for all patients, regardless of additional risk factors.4
Because statins promote progression from unstable, inflammatory atherosclerotic plaque to more stable, calcified plaque, CAC scoring is not valid in patients already on statin therapy.13
In primary prevention, patients who have been classified as having low or intermediate risk, based on ASCVD risk scoring, with a CAC score of 0 Agatston units, have an annual all-cause mortality < 1%, regardless of age and gender. Patients classified as being at high risk, based on ASCVD risk scoring, with a CAC score of 0 Agatston units, have a significantly lower annual mortality than low- or intermediate-risk patients with a CAC score > 0 Agatston units.14
20 to 39 years. Focus on evaluation of lifetime ASCVD risk, rather than short-term (10-year) risk. Lifestyle modification is the primary intervention for younger patients; for those with moderate hypercholesterolemia (LDL-C, 160-189 mg/dL) and a family history of premature ASCVD, however, consider statin therapy. For patients with LDL-C ≥ 190 mg/dL, lifetime ASCVD risk is markedly increased, and high-intensity statin therapy is recommended, regardless of age. In this group, reassess ASCVD risk factors every 4 to 6 years.4
Continue to: > 75 years, without ASCVD
