ACC/AHA Multisociety Guideline: Cholesterol Assessment and Primary ASCVD Prevention

SUMMARY:

2018/2019 ACC/AHA Multisociety Guideline on the Management of Blood Cholesterol provides recommendations for the evaluation and prevention of ASCVD. The ‘ASCVD Risk Estimator Plus for Primary Prevention’ link is provided in the ‘Learn More – Primary Sources’ section below.

Algorithm Assessment for Primary Prevention (age 40-75)

Risk Enhancers

Statin Therapy

Statin Side Effects

USPSTF and Statin Use

Algorithm Assessment for Primary Prevention (age 40-75)

Non-Diabetic

LDL-C: <70 mg/dL

  • Assess lifetime risk

LDL-C: 70-189 mg/dL

  • High Risk: 10-year risk ≥20%
    • High intensity statin
      • Aim for LDL-C lowering ≥50%
  • Intermediate Risk: 10-year risk ≥7.5% to <20%
    • ‘Risk Enhancers’ (see ‘Key Points’ below) favor starting statin therapy
    • Consider coronary artery calcium (CAC) score if statin decision uncertain
      • 0 score: Lowers risk (consider no statin, especially nonsmoker without family history of premature CHD)
      • 1-99 score: Favors statin (especially > 55 years)
      • 100+ score and/or ≥75th percentile: Initiate statin therapy
    • Moderate intensity statin
      • Aim for LDL-C lowering 30-50%
  • Boderline Risk: 10-year risk 5 to <7.5%
    • Initiate risk discussion regarding statin benefits based on risk enhancers
    • Lifestyle changes
    • Selective moderate statin
  • Low Risk: 10-year risk <5%
    • Lifestyle and risk discussion (Diet, physical activity, weight/BMI, tobacco use)

LDL-C: ≥190 mg/dL (primary severe hypercholesterolemia)

  • Maximum tolerated statin is recommended
    • If LDL-C ≥100 mg/dL: Adding ezetimibe is reasonable
    • PCSK9 inhibitor may be considered in circumstances where LDL-C baseline is very high (≥220 mg/dL) and levels remain elevated (≥130 mg/dL) despite statins and ezetimibe

Diabetic Patient

LDL-C: 70-189 mg/dL

  • Moderate intensity statin
    • Aim for LDL-C lowering 30–50%
  • High intensity statin
    • If Multiple ASCVD risk factors and 50-75 y of age
  • Diabetes-specific risk enhancers
    • Long duration (≥10 years for type 2 diabetes or ≥ 20 years for type 1 diabetes)
    • Albuminuria ≥30 mcg albumin/mg creatinine
    • eGFR <60 ml/min/1.73 m2
    • Retinopathy
    • Neuropathy
    • ABI (ankle-brachial index) <0.9

KEY POINTS:

Risk Enhancers

  • Family history of premature ASCVD
    • Males <55 years | Females <65 years
  • Primary hypercholesterolemia
    • LDL-C 160-189 mg/dL (4.1- 4.8 mmol/L)
    • Non-HDL-C 190-219 mg/dL (4.9-5.6 mmol/L)
  • Chronic kidney disease
    • eGFR 15- 59 ml/min per 1.73 m2 with or without albuminuria
    • Not treated with dialysis or kidney transplantation
  • Metabolic syndrome
  • Conditions specific to women
    • Preeclampsia
    • Premature menopause (before age 40)
  • Inflammatory disease, especially
    • Psoriasis
    • RA
    • HIV
  • Ethnicity
    • Asian American | Hispanic/ Latino Americans / Blacks
    • Heterogeneity in risk according to racial/ ethnic groups and within racial/ ethnic groups. Native American/Alaskan populations have high rates of risk factors for ASCVD compared to non-hispanic whites.”  
  • Lipid/biomarkers
    • Persistently elevated triglycerides (≥175 mg/dL)
  • Additional markers if measured
    • High sensitivity (hs)-CRP: ≥2.0 mg/L
    • Lp(a) levels: ≥50 mg/dL or ≥125 nmol/l
    • apoB: ≥130 mg/dL especially at higher levels of Lp(a)
    • Elevated apo B ≥130 mg/dL corresponds to an LDL-C >160 mg/dL and constitutes a risk enhancing factor
    • ABI (ankle-brachial index) <0.9

Lifestyle Discussion

Should be discussed and emphasized in each age group

  • Age 0-19
    • Lifestyle discussion
    • Obtain family history for Familial Hypercholesterolemia (see ‘Related ObG Topics’ below) which may require early preventative medical intervention
  • Age 20-39
    • Lifestyle discussion
    • Consider statin if
      • Family history | Premature ASCVD | LDL-C ≥160 mg/dL (≥4.1 mmol/L)
  • Age 40-75
    • LDL-C ≥70 to <190 mg/dL (≥1.8-<4.9 mmol/L) without diabetes mellitus
      • 10-year ASCVD risk percent assessment (see algorithm above)

Statin Therapy

High Intensity (≥50% LDL-C lowering)

  • Primary Statins
    • Atorvastatin 40-80 mg
    • Rosuvastatin 20 to 40 mg

Moderate-Intensity (30% to 49% LDL-C lowering)

  • Primary Statins
    • Atorvastatin 10 mg to 20 mg)
    • Rosuvastatin 5 mg to 10 mg
    • Simvastatin 40 mg
  • Other Statins
    • Pravastatin 40 mg
    • Lovastatin 40 mg
    • Fluvastatin XL 80 mg
    • Fluvastatin 40 mg BID
    • Pitavastatin 1–4 mg

Low-Intensity (<30% LDL-C lowering)

  • Primary Statins
    • Simvastatin 10 mg
  • Other Statins
    • Pravastatin 10–20 mg
    • Lovastatin 20 mg
    • Fluvastatin 20–40 mg

Note: Repeat lipid measurements and 4 to 12 weeks after starting therapy and assess response as well as lifestyle changes

Statin Side Effects

Statin Associated Muscle Symptoms (SAMS)

  • Myalgias (1 to 5% in RCT and 5 to 10% in observational studies)
  • Myositis/Myopathy (rare)
    • Weakness
  • Rhabdomyolysis (rare)
  • Statin-associated autoimmune myopathy (rare)

New Onset Diabetes

  • More common with risk factors (e.g. obesity)

Liver

  • Elevated transaminase (infrequent)
  • Hepatic failure (rare)

CNS

  • Impact on memory/cognition (rare/unclear)

Cancer

  • No definite association

Note: USPSTF differs from ACC/AHA Guidance

Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: Preventive Medication (2022)

  • Adults aged 40 to 75 years who have 1 or more cardiovascular risk factors (i.e., dyslipidemia, diabetes, hypertension, or smoking)
    • Estimated 10-year risk of a cardiovascular event of 10% or greater (Grade B): Prescribe a statin for the primary prevention of CVD
    • Estimated 10-year CVD risk of 7.5% to less than 10% (Grade C): Selectively offer a statin for the primary prevention of CVD
  • Adults 76 years or older
    • Current evidence is insufficient to assess the balance of benefits and harms of initiating a statin for the primary prevention of CVD events and mortality (Grade I)

Learn More – Primary Sources:

2018 ACC/AHA Multisociety Guideline on the Management of Blood Cholesterol

2018 AHA/ACC/AACVPR/AAPA/ABC/ ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

American College of Cardiology Foundation: 2018 Guideline on the Management of Blood Cholesterol GUIDELINES MADE SIMPLE: A Selection of Tables and Figures

New Cholesterol Guidelines Personalize Risk and Add Treatments

ASCVD Risk Estimator Plus for Primary Prevention

JAMA Viewpoint: Reexamining Recommendations for Treatment of Hypercholesterolemia in Older Adults

USPSTF: Recommendation: Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: Preventive Medication