Updated guideline on cholesterol management focuses on detailed risk assessment
The guideline from the American College of Cardiology/American Heart Association recommends that physicians talk to patients about risk-enhancing factors that can help provide a more personalized risk assessment, in addition to such traditional risk factors as smoking and high blood pressure.
Physicians discussing cardiovascular disease (CVD) risk and cholesterol management with patients should cover “risk-enhancing factors” along with traditional risk factors, according to an updated guideline from the American Heart Association (AHA) and the American College of Cardiology (ACC).
The guideline, which updates recommendations from 2013, addresses management of patients with high cholesterol levels and related disorders and is based on a review of literature published from May 1980 through July 2017. It was published by Circulation and the Journal of the American College of Cardiology on Nov. 10. An executive summary and a systematic review are also available free of charge online.
The guideline continues to recommend the risk calculator introduced in the 2013 guideline as a way to help identify patients' 10-year CVD risk. However, since the calculator uses population-based formulas, the guideline recommends that physicians talk to patients about risk-enhancing factors that can help provide a more personalized risk assessment, in addition to such traditional risk factors as smoking and high blood pressure. Risk-enhancing factors include family history and ethnicity, metabolic syndrome, chronic inflammatory conditions, and high lipid biomarkers, among others.
Statins are recommended as first-line treatment for primary and secondary prevention in patients whose high cholesterol levels cannot be controlled by diet or exercise. The guideline recommends select use of other cholesterol-lowering drugs in addition to statins in patients who have clinical atherosclerotic CVD, who are considered high risk, and whose LDL cholesterol levels are not responding adequately to statin therapy. Ezetimibe is recommended first, and if this is not effective, a PCSK9 inhibitor (evolocumab or alirocumab) could be added in patients who are at very high risk, although the long-term safety of these drugs is not certain and cost-effectiveness at mid-2018 list prices is low, the guideline said. The guideline noted that this approach could also be considered in patients with severe primary hypercholesterolemia.
The guideline also addressed the use of coronary artery calcium in clinical decision making. For intermediate-risk adults or selected borderline-risk adults with a coronary artery calcium score of zero, withholding statin therapy and reassessing in five to 10 years is reasonable as long as no conditions conferring higher risk, such as diabetes or smoking, are present. Statin therapy initiation is considered reasonable in patients ages 55 years or older with a coronary artery calcium score of 1 to 99 and in any patient with a coronary artery calcium score of 100 or in the 75th percentile or higher, the guideline said.
Response to any intervention, including lifestyle modification, should be assessed at four to 12 weeks, the guideline said, and assessments should be repeated every three to 12 months as needed. Percentage reductions in LDL cholesterol levels should be compared with baseline. In patients with atherosclerotic CVD who are at very high risk, addition of nonstatin drugs should be triggered by an LDL cholesterol level of 70 mg/dL or higher while on maximal statin therapy, the guideline said.
The AHA and ACC also published a report as a companion to the guideline discussing the use of quantitative risk assessment in primary prevention of CVD, including the rationale and evidence base, the strengths and limitations of existing risk scores, approaches for refining individual risk estimates for patients, and practical advice on implementation of risk assessment and decision-making strategies.