Acc 2018 guidelines on lipids

Focus of Guidelines
• Primary and Secondary Atherosclerotic Cardiovascular Disease
(ASCVD) Prevention
• Four statin benefit groups:
Secondary ASCVD Prevention
Severe Hypercholesterolemia (LDL-C ≥190 mg/dL)
Diabetes Mellitus in Adults 40-75 Years of Age With LDL-
C 70-189 mg/dL
Primary Prevention Over the Life Span
• Importance of identifying Coronary Artery Calcium score( CAC
score)

ACC/AHA 2018 Cholesterol Guideline
High Blood Cholesterol and
Atherosclerotic CardiovascularDiseases
(ASCVD) Risk

LDL-C levels and high prevalence of
Cardiovascular Events
Journal of Clinical Lipidology (2014) 8, 29–60

ASCVD Risk classification
ASCVD Risk Risk category
Low risk <5%
Borderline risk 5% - <7.5%
Intermediate risk ≥7.5% to <20%
High risk ≥20%
J Am Coll Cardiol. 2018:1-80

Major Atherosclerotic Cardiovascular Disease
Risk Factors
Major risk factors Additional risk factors
Nontraditional risk
factors
Advancing age
⇧ Total serum cholesterol
level
⇧ Non–HDL-C
⇧ LDL-C
Low HDL-C
Diabetes mellitus
Hypertension
Stage 3 or 4 chronic
kidney disease
Cigarette smoking
Family history of ASCVD
Obesity, abdominal obesity
Family history of
hyperlipidemia
⇧ Small, dense LDL-C
⇧ Apo B
⇧ LDL particle concentration
Fasting/postprandial
hypertriglyceridemia
PCOS
Dyslipidemic triad
⇧ Lipoprotein (a)
⇧ Clotting factors
⇧ Inflammation
markers
(hsCRP; Lp-PLA2)
⇧ Homocysteine levels
Apo E4 isoform
⇧ Uric acid
⇧ TG-rich remnants

Management of Dyslipidemia
Overview of ACC/AHA 2018 Cholesterol
Guideline

History of U.S. Dyslipidemia Guideline
Development

NCEP ATP III Updated Report:
LDL-C Goals Based on Risk Category
Grundy et al. Circulation.2004;110:227

The New 2018 ACC/AHA Cholesterol
Guidelines:
What is New
• LDL-C <70 mg/dl is required for very high risk ASCVD patients
• For patients with severe primary hypercholesterolemia,
achieve LDL-C <100 mg/dl with statins. Add Ezetimibe and/or
PCSK9 inhibitors if required
• Start moderate dose statin in diabetes patients without
measuring 10 years ASCVD risk

The New 2018 ACC/AHA Cholesterol
Guidelines:
What is New
• For 40-75 years, non-diabetic patients with LDL-C 70-189
mg/dl clinician patient discussion is required to start statin if
10 years ASCVD risk is >7.5%
• CAC (Coronary Artery Calcium Score) can help to take decision
on starting statin in primary prevention.
• Being South Asian is a risk enhancer for ASCVD, favors
initiation of statin therapy in non-diabetic patients for primary
prevention

High intensity statin therapy should be initiated as first line
therapy for 50% or greater LDL reduction
In patients whom high intensity statin therapy is contraindicated
or who experience statin associated side effects, moderate-
intensity statin therapy should be initiated for achieving a 30% to
49% reduction in LDL-C levels
Secondary ASCVD Prevention in Patients aged 75
years or younger with clinical ASCVD

In patients considered for PCSK9 inhibitor therapy, maximally
tolerated LDL-C lowering therapy should include maximally
tolerated statin therapy and ezetimibe
In patients who are on maximally tolerated LDL-C lowering
therapy with LDL-C 70 mg/dL or higher or a non-HDL-C level of
100 mg/dLor higher, it is reasonable to add a PCSK9 inhibitor

Patients on maximally tolerated statin therapy and are judged to
be at very high risk and have an LDL-C level of 70 mg/dL or
higher, it is reasonable to add ezetimibe therapy

Initiate moderate or high intensity statin therapy after
evaluation of the potential for ASCVD risk reduction
Patients who are tolerating high-intensity statin therapy, it is
reasonable to continue high-intensity statin therapy after
evaluation of the potential for ASCVD risk reduction
years or older with clinical ASCVD

Secondary ASCVD Prevention in Patients with
LDL-C> 70 mg/dL and clinical ASCVD
It may be reasonable to add ezetimibe in patients
receiving maximum tolerated statin dose

In patients with heart failure (HF) with reduced ejection
fraction attributable to ischemic heart disease who have a
reasonable life expectancy (3 to 5 years) and are not already on a
statin because of ASCVD, initiate moderate-intensity statin therapy
to reduce the occurrence of ASCVD events
Secondary ASCVD Prevention in Patients with
heart failure with reduced ejection fraction

Approach towards Secondary Prevention

Patients at Very High Risk of Future ASCVDEvents

High Risk Conditions associated with ASCVD

Recommendations for Primary Severe
Hypercholesterolemia LDL-C ≥190 mg/dL

Maximally tolerated statin therapy is recommended
Patients achieving less than 50% reduction in
LDL-C while receiving maximally tolerated statin therapy and/or
have an LDL-C level of 100 mg/dL or higher, ezetimibe
therapy is reasonable
Primary Severe Hypercholesterolemia in patients
aged 20-75 years with LDL-C ≥190 mg/dL

Patients achieving less than a 50% reduction
in LDL-C levels and have fasting triglycerides 300 mg/dL while taking
maximally tolerated statin and ezetimibe
therapy, the addition of a bile acid sequestrant may be considered
aged 20-75 years with LDL-C ≥190 mg/dL and
Triglycerides ≥ 300 mg/dL

In patients 30 to 75 years of age with heterozygous FH and with an
LDL-C level of 100 mg/dL or higher while taking
maximally tolerated statin and ezetimibe therapy, the addition of a
PCSK9 inhibitor may be considered

Patients achieving an on-treatment LDL-C
level of 130 mg/dL or higher while receiving
maximally tolerated statin and ezetimibe therapy, the
addition of a PCSK9 inhibitor may be considered

Recommendations for Adults with Diabetes
Melitus

Risk Enhancers in Diabetes Mellitus

Initiate moderate intensity statin therapy regardless of
estimated 10 year ASCVD risk
In diabetes patients with LDL-C level of 70 to 189 mg/dL ,
it is reasonable to assess the 10 year risk of a first ASCVD
event
Diabetes Melitus in patients aged 40-75 years

Patients with multiple ASCVD risk factors, use high-intensity statin
therapy to reduce LDL-C levels by 50% or more
Patients with LDL-C level of 70 to 189 mg/dL , 10 year risk of a first
ASCVD event sholud be assessed
Diabetes Melitus in patients aged 75 yeras or
older
Patients with 10 year ASCVD risk of
20% or higher, add ezetimibe to maximally tolerated statin
therapy to reduce LDL-C levels by 50% or more

Initiate statin therapy in Diabetes patients with
•Long duration Diabetes (≥10 years of type 2 diabetes mellitus,
≥20 years of type 1 diabetes mellitus)
•Albuminuria (≥30 mcg of albumin/mg creatinine)
•eGFR less than 60 mL/min/1.73 m2
•Retinopathy,
•Neuropathy
•Ankle-brachial index (ABI <0.9)
Diabetes Melitus in patients aged 20-39 years

Recommendations for Primary Prevention

Risk Enhancing Factors for Clinician-Patient
Risk Discussion

In adults at intermediate risk , statin therapy reduces risk of
ASCVD. Use of moderate intensity statin is recommended
10 year ASCVD risk of a first ASCVD event (fatal and nonfatal MI
or stroke) should be estimated
Primary Prevention in Adults 40 to 75 Years
In intermediate or borderline risk adults, if the decision about
statin use remains uncertain, it is reasonable to use a Coronary
Artery Calcium (CAC) score to initiate statin
LDL-C Levels 70 to 189 mg/dL and without Diabetes

Primary Prevention in Adults 40 to 75 Years
CAC Score Statin Use
0 Withhold statin therapy, unless diabetes, family
history of premature CHD, or cigarette smoking are
present
Reassess in 5 to 10 years
1-99 Favors statin (especially after age 55)
100+ and/or 75th
percentile
Initiate statin therapy
LDL-C Levels 70 to 189 mg/dL and without Diabetes

Levels of CAC score indicating 75th percentile
for age, sex, and race/ethnicity

Candidates for Coronary Artery Calcium
Measurement Who Might Benefit from Knowing
CAC Score is Zero

Treatment Considerations

Primary Prvention
Assessing ASCVD risk in each Age group

Summary
Primary and Secondary ASCVD Prevention

Initiate a moderate intensity statin may be reasonable
Stop statin therapy when functional decline (physical or cognitive),
multimorbidity, frailty, or reduced life-expectancy limits the
potential benefits of statin therapy
Primary Prevention in Older Adults of age 75
years or more With LDL-C Levels 70 to 189 mg/dL

Measure CAC to reclassify those with a CAC score of zero
to avoid statin therapy
Primary Prevention in Older Adults of age 76-80
years
With LDL-C Levels 70 to 189 mg/dL

Initiate a moderate intensity statin may be reasonable
Stop statin therapy when functional decline (physical or cognitive),
multimorbidity, frailty, or reduced life-expectancy limits the
potential benefits of statin therapy
Primary Prevention in Children and Adolescents of
10 years of age or older
Measure fasting lipid profile to detect lipid disorders as
components of the metabolic syndrome as early as age 2 years to
detect Familial Hypercholesteremia or rare forms of
hypercholesterolemia
LDL-C level >190 mg/dL >160 mg/dL

In children and adolescents without cardiovascular risk factors or
family history of early CVD,measure a fasting lipid profile or
nonfasting non HDL-C once between the ages of 9 and 11 years,
and again between the ages of 17 and 21 years, to detect
moderate to severe lipid abnormalities
Primary Prevention in Children and Adolescents of
10 years of age or older
LDL-C level >190 mg/dL >160 mg/dL

Normal and Abnormal Lipid Values in Childhood

Treat lifestyle factors (obesity and metabolic syndrome),
secondary factors (diabetes mellitus, chronic liver or kidney
disease and/or nephrotic syndrome, hypothyroidism)
Hypertriglyceridemia in adults 20 years or older
Triglycerides 175 to 499 mg/dL

Address reversible causes of high triglyceride and to initiate statin
therapy
Hypertriglyceridemia in adults 40 to 75 years
Triglycerides ≥500 mg/dL and ASCVD risk of 7.5% or higher

Hypertriglyceridemia in adults with 40 to 75
years
If triglycerides are persistently elevated or increasing , reduce
triglycerides by implementation of a very low fat diet, avoidance
of refined carbohydrates and alcohol, consumption of omega-3
fatty acids, and, if necessary to prevent acute pancreatitis,
fibrate therapy
Triglycerides ≥1000 mg/dL and ASCVD risk of 7.5% or higher

Patients not treated with dialysis or kidney transplantation
initiation of a moderate-intensity statin or moderate-intensity
statins combined with ezetimibe can be useful
Adults 40 to 75 years of age
Continue statin therapy in adults with advanced kidney disease
requiring dialysis treatment who are currently on LDL-lowering
therapy with a statin
With LDL-C 70 to 189 mg/dL who are at 10-year ASCVD risk of 7.5% or
higher and Chronic Kidney Disease

Moderate-intensity statin therapy or high-intensity statin therapy
should be given
Adults 40 to 75 years of age
In adults with Rheumatois Arthritis , it can be useful to recheck
lipid values and other major ASCVD risk factors 2 to 4 months after
the patient’s inflammatory disease has been controlled
With LDL-C 70 to 189 mg/dL who are at 10-year ASCVD risk of 7.5% or
higher and Chronic Inflammatory disorder and HIV

Take Home Messages
2018 ACC/AHA Cholesterol Guidelines

Focus on PersonalizedTreatment Goal
• In all individuals, emphasize a heart healthy lifestyle across
the life course
• In patients with clinical ASCVD, reduce LDL-C with high-
intensity statin therapy or maximally tolerated statin therapy
• Use non statin therapy like ezetemibe or PCSK9 inhibitors in
very hig risk ASCVDand use a LDL-C threshold of 70 mg/dL
• In patients with severe primary hypercholesterolemia (LDL-C
level ≥ 190 mg/dLwithout calculating 10-year ASCVD
risk,begin high-intensity statin therapy without calculating
10-year ASCVD risk

Focus on Personalized Treatment Goal
• In adults 40 to 75 years of age evaluated for primary ASCVD
prevention, have a clinician patient risk discussion before
starting statin therapy.
• In adults 40 to 75 years of age without diabetes mellitus and
with LDL-C levels ≥70 mg/dL , at a 10-year ASCVD risk of
≥7.5%, start a moderate intensity statin if a discussion of
treatment options favors statin therapy.
10 year risk of 7.5%-19.9%, risk enhancing factors favor
initiation of statin therapy.

Focus on Personalized Treatment Goal
with LDL-C levels ≥70 mg/dL 189 mg/dL, 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)
• Assess adherence and percentage response to LDL-C lowering
medications and lifestyle changes with repeat lipid
measurement 4 to 12 weeks after statin initiation or dose
adjustment, repeated every 3 to 12 months as needed

Acc 2018 guidelines on lipids

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