Spotlight from the American Society for Preventive Cardiology on Key Features of the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guidelines on the Management of Blood Cholesterol
The 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol retains focus on recommendations for statin treatment in the original four statin-eligible groups [those with atherosclerotic cardiovascular disease (ASCVD), diabetes, low-density lipoprotein cholesterol (LDL-C) ≥ 190 mg/dL, and higher risk primary prevention] without the use of treatment initiation or target LDL-C levels from the earlier 2013 American College of Cardiology/American Heart Association (ACC/AHA) guideline, but has several new features. First, patients with primary prevention are divided into those who are at low (< 5%), borderline (5% to < 7.5%), intermediate (7.5% to < 20%), and high (≥ 20%) risk based on the ASCVD risk estimator. Moreover, the new guideline goes further to consider a wider range of factors [now called “risk enhancers”—premature family history of ASCVD, persistently high LDL-C, chronic kidney disease (CKD), metabolic syndrome, conditions specific to women, inflammatory diseases, and high-risk ethnicities] that can be used to better inform the treatment decision. Moreover, more detailed recommendations on how the results of coronary calcium scanning can be used to inform the treatment decision are provided, including how it may be used to “de-risk” certain patients for delaying or avoiding the use of statin therapy. There are also specific sections for cholesterol management in other patient subgroups including women, children, certain ethnic groups, those with CKD, chronic inflammatory disorders and HIV, as well as discussion on the management of hypertriglyceridemia. Importantly, for persons with known ASCVD, a distinction is made for those who are at “very high risk” based on having had two major ASCVD events or one major event and two or more other high risk conditions, such as diabetes or other major risk factors, or bypass surgery or percutaneous intervention. Finally, the concept of a threshold LDL-C for initiating a non-statin therapy (after considering highest tolerated statin dosage) is provided, with ezetimibe recommended as the key non-statin to be added if the LDL-C still remains ≥ 70 mg/dL for all ASCVD patients, and in those who are at “very high risk”, further consideration for using a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor. While the new guideline does have greater detail (and arguably, complexity), the refinements provide a strategy for guiding the clinician to target both statin and non-statin therapy to those most likely to derive benefit.
Compliance with Ethical Standards
No external funding was used in the preparation of this manuscript.
Conflict of interest
Nathan D. Wong, PhD, has received research support through the University of California, Irvine, from Amgen, Amarin, Novo Nordisk, and Boehringer Ingelheim; speaking fees from Amarin and Sanofi; and consulting fees from Amarin and Novartis. Peter Toth, MD, PhD, notes speaking fees from Amarin, Amgen, Kowa, Nova Nordisk, Regeneron, and Sanofi, and consultant/advisory board participation for Amarin, Amgen, Kowa, Nova Nordisk, Regeneron, and Sanofi. Christie Ballantyne, MD, has received speaking fees from Akcea, Amgen, Esperion, Novartis, Regeneron, and Sanofi-Synthelabo (all paid to institution, not individual), and consulting fees or honorarium from Akcea, Amarin, Amgen, Arrowhead, AstraZeneca, Boehringer Ingelheim, Esperion, Intercept, Janssen, Matinas BioPharma Inc., Merck, Novartis, Novo Nordisk, Regeneron, and Sanofi-Synthelabo. Ezra A. Amsterdam, MD, Amit Khera, MD, and Khurram Nasir, MD, MPH, declare no potential conflicts of interest that might be relevant to this article.
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