How do lipid disorder treatment recommendations vary among guidelines?

Updated: Nov 30, 2018
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Like the ACC/AHA-ASCVD risk calculator, the 2013 joint ACC/AHA guidelines have been mired in controversy. The new guidelines departed significantly from previous iterations by abandoning the traditional LDL and non-HDL cholesterol targets. Physicians are no longer asked to treat patients who have cardiovascular disease to an LDL of less than 100 mg/dL or the optional goal of less than 70 mg/dL.

Instead, the new guidelines identify four groups of primary- and secondary-prevention patients in whom physicians should focus their efforts to reduce cardiovascular-disease events. Depending on the type of patient, physicians should choose the appropriate "intensity" of statin therapy to achieve relative reductions in LDL cholesterol.

The clinical guidelines currently state that for patients with atherosclerotic cardiovascular disease, high-intensive statin therapy should be used to achieve at least a 50% reduction in LDL cholesterol unless otherwise contraindicated or when the patient experiences statin-associated adverse events. In that case, doctors should use a moderate-intensity statin.

Similarly, for those with LDL-cholesterol levels ≥190 mg/dL, a high-intensity statin should be used with the goal of achieving at least a 50% reduction in LDL cholesterol levels. However, for patients >75 years of age and those with safety concerns and CAD, a moderate-intensity statin can be used.

For those with diabetes aged 40 to 75 years of age, a moderate-intensity statin, defined as a drug that lowers LDL cholesterol 30-49%, should be used, whereas a high-intensity statin is a reasonable choice if the patient also has a 10-year risk of atherosclerotic cardiovascular disease exceeding 7.5%.

For the individual aged 40 to 75 years without cardiovascular disease or diabetes but who has a 10-year risk of clinical events >7.5% and an LDL cholesterol level of 70 to 189 mg/dL, the panel recommends treatment with a moderate- or high-intensity statin. Also, in a significant departure from previous guidelines, the 2013 ACC/AHA guidelines recommend measurement of LDL-C during therapy only as an assessment of adherence and response to therapy. [24]

The AACE and NLA have declined to endorse the guidelines. In particular, the AACE disagrees with removal of the LDL targets and the idea that statin therapy alone is sufficient for all at-risk patients, noting that many who have multiple risk factors, including diabetes and established heart disease, will need additional therapies. [25]

A summary of the recommendations for intervention are detailed in Table 4, below.

Table 4. Guidelines for Intervention (Open Table in a new window)

Adult Guidelines

Year

Risk Algorithm

Intervention Population

Treatment Goal

Intervention

American College of Cardiology/American Heart Association (ACC/AHA) [24]

2013

ACC/AHA-ASCVD

Adults ≥21 years old in any of the following risk groups:

  1. Known ASCVD
  2. LDL-C >190 mg/dL
  3. 40-75 years old, with diabetes and LDL-C levels 70-189 mg/dL and no ASCVD
  4. ≥7.5% 10 year ASCVD risk with LDL-C levels 70-189 mg/dL

By Risk Group:

  1. ≥50% reduction in LDL-C
  2. ≥50% reduction in LDL-C
  3. 30-50% reduction in LDL-C
  4. 30-50% reduction in LDL-C

High-intensity statin therapy for most patients in groups 1 and 2, and for group 3 patients if ≥7.5% 10- year ASCVD risk; consider for group 4

 

 

Moderate-intensity statins for group 1-2 patients >75 years or with statin-associated adverse events, and for most group 3-4 patients

American Association of Clinical Endocrinologists(AACE) [25]

2012

Men: FRS

Women: RRS

All adults: LDL-C level >100 mg/dL

Very High Risk: LDL-C level >70 mg/dL

Primary:

All adults: LDL-C < 100 mg/dL

Very High Risk: LDL-C < 70 mg/dL

Secondary:

HDL-C >40 mg/dL

Non-HDL-C  30 mg/dL above LDL-C goal

TG < 150 mg/dL

apoB < 90 mg/dL; < 80 for those with CVD or diabetes and additional risk factor(s)

Lifestyle changes (First- Line):

Physical activity, nutrition counseling, smoking cessation and weight loss.

Pharmacologic Therapy:

  • Statins are drug of choice for LDL-C reduction
  • Fibrates for treatment of TG>500 mg/dL
  • Niacin for reducing TG and LDL-C, and increasing HDL-C
  • Bile acid sequestrants for reducing LDL-C and apoB; may increase TG
  • Cholesterol absorption inhibitors for reducing LDL-C and apoB in combination with statins

National Lipid Association (NLA) [26]

2014

N/A

Low Risk: Non-HDL-C ≥190 mg/dL; LDL-C ≥160 mg/dL

Moderate Risk: Non-HDL-C ≥160 mg/dL; LDL-C ≥130 mg/dL

High Risk: Non-HDL-C ≥130 mg/dL; LDL-C ≥100 mg/dL

Very High Risk: Non-HDL-C ≥100 mg/dL; LDL-C ≥70mg/dL

Primary:

Low, Moderate, or High Risk:

Non-HDL-C < 130 mg/dL

LDL-C < 100 mg/dL

Very High Risk:

Non-HDL-C < 100 mg/dL

LDL-C < 70 mg/dL

Low to Moderate Risk;

First-line lifestyle changes should be monitored for 6-12 months; pharmacologic treatment can be added if levels remain elevated

High to Very High Risk:

Pharmacologic therapy should be initiated with lifestyle changes;

Lifestyle changes:

Nutrition counseling, physical activity, smoking cessation and weight loss.

Pharmacologic Therapy:

Moderate to high intensity statin; if very high TG ≥500mg/dL, TG lowering drug to prevent pancreatitis

Department of Veterans Affairs/Department of Defense (VA/DOD) [27]

2014

10-year risk calculator (ie, FRS-CVD, ACC/AHA-ASCVD)

10-year CVD risk ≥12%;

Consider pharmacologic intervention in patients with 10-year CVD risk ≥6% and < 12%;

Patients with established ASCVD risk

CVD risk reduction

Pharmacologic Therapy:

Moderate intensity statin; high intensity only for select patient populations (e.g., recurrent CVD events while on moderate-intensity statins)

Lifestyle changes:

Nutrition counseling, physical activity, smoking cessation and weight loss.

For patients unable to tolerate statin therapy, consider fibrates or bile acid sequestrants (BAS), but recommends against non-statin lipid lower drugs as monotherapy or in combination with statins for patients able to tolerate statin therapy

International Atherosclerosis Society (IAS) [5]

2014

Lifetime-FRS (preferred) or QRISK2

Non-HDL-C ≥130 mg/dL; LDL-C ≥100 mg/dL

LDL-C < 100 mg/dL

Non-HDL-C < 130 mg/dL is an alternative target

Lifestyle changes(First line):

Nutrition counseling, physical activity, smoking cessation and weight loss.

Pharmacologic Therapy in addition to lifestyle changes:

Moderate to high intensity statin adjusted to absolute risk

European Society of Cardiology/ European Atherosclerosis Society (ESC/EAS) [28]

2011

SCORE

Moderate Risk: LDL-C >115 mg/dL

High Risk:  LDL-C >100 mg/dL

Very High Risk:  LDL-C >70 mg/dL

Primary:

Moderate Risk: LDL-C < 115mg/dL

High Risk: LDL-C < 100mg/dL

Very High Risk: LDL-C < 70 mg/dL or 50% reduction

Secondary: Non-HDL-C or apoB in patients with metabolic syndrome, diabetes, or chronic kidney disease

Lifestyle changes:

Nutrition counseling, physical activity, smoking cessation and weight loss.

Pharmacologic Therapy:

Statins up to the highest recommended and/or tolerable dose;

BAS, niacin or cholesterol absorption inhibitor may be given in combination with statin if target level not reached;

BAS and niacin in cases of statin intolerance; cholesterol absorption inhibitor may be considered as monotherapy or in combination with BAS or niacin

apoB = apolipoprotein B, ASCVD = atherosclerotic cardiovascular disease, CVD = cardiovascular disease, FRS = Framingham risk score, HDL-C = high-density lipoprotein cholesterol, LDL-C = low-density lipoprotein cholesterol, TG = triglycerides.

2018 ACC/AHA/multisociety guideline

The recommendations on management of blood cholesterol were released in November 2018 by the ACC, AHA, and multiple other medical societies.  [31, 32]

The guideline's top 10 key recommendations for reducing the risk of atherosclerotic cardiovascular disease through cholesterol management are summarized below.

Emphasize a heart-healthy lifestyle across the life course of all individuals.

In patients with clinical atherosclerotic cardiovascular disease (ASCVD), reduce low-density lipoprotein cholesterol (LDL-C) levels with high-intensity statin therapy or the maximally tolerated statin therapy.

In individuals with very high-risk ASCVD, use an LDL-C threshold of 70 mg/dL (1.8 mmol/L) to consider the addition of nonstatins to statin therapy.

In patients with severe primary hypercholesterolemia (LDL-C level ≥190 mg/dL [≥4.9 mmol/L]), without calculating the 10-year ASCVD risk, begin high-intensity statin therapy.

In patients 40 to 75 years of age with diabetes mellitus and an LDL-C level of ≥70 mg/dL: Start moderate-intensity statin therapy without calculating their 10-year ASCVD risk.

In patients aged 40 to 75 years evaluated for primary ASCVD prevention: Have a clinician–patient risk discussion before starting statin therapy.

In nondiabetic patients aged 40 to 75 years and with the following characteristics:

  • LDL-C levels ≥70 mg/dL (≥1.8 mmol/L), at a 10-year ASCVD risk of ≥7.5%: Start a moderate-intensity statin if a discussion of treatment options favors statin therapy.

  • A 10-year risk of 7.5-19.9% (intermediate risk): Risk-enhancing factors favor initiation of statin therapy.

  • LDL-C levels ≥70-189 mg/dL (≥1.8-4.9 mmol/L), at a 10-year ASCVD risk of ≥7.5-19.9%: If a decision about statin therapy is uncertain, consider measuring coronary artery calcium (CAC) levels.

Assess patient adherence and the percentage response to LDL-C–lowering medications and lifestyle changes with a repeat lipid measurement 4-12 weeks after initiation of statin therapy or dose adjustment; repeat every 3-12 months as needed.

 


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