Translating AHA/ACC cholesterol guidelines into meaningful risk reduction
The new recommendations detail refined, personalized lipid management and emphasize multiple levels of evidence. The result? Care is more complex but patients might benefit more.
PRACTICE RECOMMENDATIONS
› Reduce the low-density lipoprotein cholesterol (LDL-C) level in patients with clinical atherosclerotic cardiovascular disease (ASCVD) using high-intensity statin therapy or maximally tolerated statin therapy. A
› Use an LDL-C threshold of 70 mg/dL to prompt consideration of adding nonstatin therapy in patients who have very high-risk ASCVD. A
› Start high-intensity statin therapy in patients who have primary hypercholesterolemia (LDL-C level ≥ 190 mg/dL) without calculating the 10-year ASCVD risk. A
› Begin moderate-intensity statin therapy in patients 40 to 75 years of age who have diabetes mellitus and an LDL-C level ≥ 70 mg/dL without calculating 10-year ASCVD risk. A
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
Routine CK and liver function testing is not useful in patients treated with statins; however, it is recommended that CK be measured in patients with severe SAMS or objective muscle weakness, or both, and to measure liver function if symptoms suggest hepatotoxicity. In patients at increased risk for ASCVD who have chronic, stable liver disease (including non-alcoholic fatty liver disease), it is reasonable, when appropriately indicated, to use statins after obtaining baseline measurements and determining a schedule of monitoring and safety checks.
In patients at increased risk for ASCVD who have severe or recurrent SAMS after appropriate statin rechallenge, it is reasonable to use nonstatin therapy that is likely to provide net clinical benefit. The guideline does not recommend routine use of coenzyme Q10 supplementation for the treatment or prevention of SAMS.1
Guideline criticism
Guideline development is challenging on multiple levels, including balancing perspectives from multiple stakeholders. Nevertheless, the 2018 AHA/ACC cholesterol guideline builds nicely on progress made since its 2013 predecessor was released.4 This document was developed with the participation of representatives from 10 professional societies in addition to the ACC and AHA—notably, the National Lipid Association and American Society for Preventive Cardiology.1
To refine risk estimation and facilitate shared decision-making, the new guideline introduced so-called risk-enhancing factors and use of the CAC.1 However, some potential risk-enhancing factors were left out: erectile dysfunction, for example, often a marker of increased cardiovascular risk in men < 50 years of age.25 In addition, although pretreatment ApoB was introduced as a risk-enhancing factor,1 no recommendation is given to measure ApoB after initiation of therapy for evaluation of residual cardiovascular risk, as endorsed in other guidelines.26,27
Moreover, the guideline does not include the “extreme risk” category in the guideline developed by the American Association of Clinical Endocrinologists (AACE).28 Although the 2018 AHA/ACC guideline introduces < 70 mg/dL and < 100 mg/dL LDL-C thresholds,1 the < 55 mg/dL LDL-C threshold used for patients in the AACE/American College of Endocrinology extreme-risk category is not mentioned.26 This omission might leave patients who are at extreme ASCVD risk without optimal lipid-lowering therapy. Similarly, the guideline does not elaborate on the diagnosis and treatment of HoFH and HeFH.1 The age cutoff of 30 years for the recommendation to consider PCSK9 inhibitors in patients with HeFH appears arbitrary and excludes younger FH patients who have an extreme LDL-C elevation from potentially important therapy.23
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