2020 Lipid Guidelines Review – Part 1 – The Curbsiders #191 Lipids Update And Cardiovascular Risk

These are my three 2020 posts on recent Lipid Guidelines:

I started my review of this topic with the outstanding podcast and show notes #191 Lipids Update and Cardiovascular Risk Reduction with Erin Michos MD: PRIMARY AND SECONDARY PREVENTION OF CARDIOVASCULAR DISEASE from The Curbsiders.JANUARY 20, 2020 By CHRIS CHIU 2 COMMENTS.

What follows are notes to myself on how to review this topic.

The podcast, show notes, and Infographics are simply incredible.

Start by listening to the podcast which I have embedded below:

Next review the infographics and show notes again.

I’ve included the infographics but the I need to review the show notes here again. The show notes are perfect so just review them on the site.

The podcast and show notes of Curbsiders #191 are basically a complete review of the 2018 ACC/AHA Guidelines in an incredibly useful format. I review  the 2018 ACC/AHA Guidelines themselves in 2020 Lipid Guidelines Review – Part 2

Here are excerpts:

Lipids Update – Top Pearls

  1. Lifestyle changes are the cornerstone and foundation of cardiovascular prevention and should never be neglected in our conversations with patients. “Primordial prevention” is key! A patient’s risk of plaque burden is not only from the magnitude of LDL elevation but duration of exposure
  2. In primary prevention, the new ASCVD risk categories include low risk (< 5%), borderline risk (5 to <7.5%), intermediate risk (7.5 to <20%), and high risk (≥20%). The focus of the 2018 lipid guideline update is on risk-enhancing factors. Use risk-enhancers (e.g. family history, chronic inflammatory disorders, pregnancy-related adverse outcomes) to guide management for patients in the borderline and intermediate risk groups
  3. Biomarkers that can be checked include Lp(a), ApoB, and high-sensitivity CRP, and can be helpful to further risk-stratify. Dr. Michos usually checks Lp(a) once in patients with strong family history and personal history of premature CAD. ApoB is checked when close to LDL goal to assess further need for reduction.
  4. Coronary artery calcium scoring is a very useful and reliable tool for the tie-breaker in starting a statin, especially in patients who are reluctant to start a statin.
  5. The risk of rhabdomyolysis from statins is < 0.1% and risk of liver injury is 1 in 100,000. 
  6. Start low and go slow! Dr. Michos offers great advice in working with patients who claim to have statin “intolerance”, which the guidelines say to call “statin-associated muscle symptoms”. She recommends starting patients at a low dose and working your way up which helps with building rapport and trust from the patient.
  7. LDL reduction goals depend on statin intensity: with a high-intensity statin, expect an LDL reduction by > 50%, 30%-49% with moderate-intensity, and < 30% with low-intensity statin.
  8. For follow up, the guidelines recommend checking LDL 4-12 weeks after initiation, then 3-13 months depending on the individual patient’s situation. In stable patients, you can check yearly, and as often as every 4-6 years in younger patients.
  9. In secondary prevention, add ezetimibe when LDL goal has not been met, followed by PCSK9 inhibitor for further LDL reduction.
  10. Aspirin for primary prevention is now falling out of favor (a IIb recommendation and class III recommendation in elderly > 70). Statins and lifestyle modification are first line for patients with triglycerides > 500, however fibrates can be added when triglycerides > 1000. Icosapent ethyl is a great option, reduced major cardiovascular events by 25% in the REDUCE-IT trial, but insurance coverage may still an issue. Fish oil and icosapent ethyl are NOT the same!

Here are the Infographics from Curbsiders #191:


Here are more excerpts from #191:

ACC/AHA ASCVD Risk Calculator

The ASCVD risk calculator that we all know so well is one of many cardiovascular disease calculators out there, but this one is specifically recommended by the guidelines since 2013 for its use (Goff, 2013).

Kashlak Pearl: Whose risk should be assessed with this calculator? Anyone who is between the ages of 40 and 75 years-old who doesn’t have diabetes and has an LDL between 70 and 189. You got that?

Why the Update in 2018?

The guideline recommendations in 2013 encouraged widespread use of the calculator for assessing ASCVD risk and, therefore, treatment strategy with statins. But many realized that the calculator is not necessarily perfect, as it does not take into account lots of other risk enhancing factors (more below) that would put someone at a much higher risk for clinical ASCVD than what this calculator would predict. Per Dr. Michos, the 2018 update is much more personalized, and making the decision to start a statin, especially in primary prevention, is much more a patient-centered endeavor (Grundy, 2018).

Risk Categories and Recommendations

We now have 4 ASCVD risk categories per the 2018 update. These are according to the patient’s 10-year ASCVD risk:

  • Low: < 5%
  • Borderline: 5- <7.5%
  • Intermediate: 7.5- <20%
  • High: > 20%

For patients in the “intermediate” risk category, start a moderate-intensity statin based on discussion with the patient and particularly with the presence of risk-enhancing factors (class I recommendation).

For patients in the “borderline” risk category, consider a moderate-intensity statin based on patient discussion and the presence of risk-enhancing factors (class IIb recommendation).

Other Groups

Patients with diabetes mellitus and age between 40 and 75 years require at least a moderate-intensity statin (class I) or high-intensity statin (class IIa with additional risk factors) regardless of ASCVD risk.

Patients with LDL > 190 mg/dL also require a high-intensity statin regardless of ASCVD risk (class I).

Risk Enhancing Factors

What are these risk-enhancing factors specifically? (Grundy, 2018)

  • Family history of premature ASCVD (male < 55 years or female < 65 years)
  • Primary hypercholesterolemia with LDL 160-189 mg/dL
  • Metabolic syndrome
  • Chronic kidney disease
  • Chronic inflammatory disorders (e.g. rheumatoid arthritis, HIV/AIDS)
  • Premature menopause (< 40 years)
  • Pregnancy-associated complications with higher ASCVD risk (e.g. preeclampsia)
  • High-risk ethnicities (e.g. South Asian)
  • Non-fasting triglycerides > 175 mg/dL on at least 3 occasions
  • Biomarkers: high-sensitivity CRP > 2 mg/dL, Lp(a) > 50 mg/dL, apoB > 130 mg/dL
  • ABI < 0.9


Dr. Michos usually checks lipoprotein (Lp) (a) in anyone who has a very strong family or personal history of premature CAD. Lp(a) is genetically-inherited and is worth it to check once in such patients. There might be some targeted therapies for this in the future!

She also checks an apolipoprotein B (apoB) level when she is getting close to the appropriate LDL goal. The Friedewald equation which estimates LDL levels is imperfect, and atherogenic particles are important to check to see if you need to escalate therapy.

Coronary Artery Calcium Scoring

A more accurate way to risk-stratify your patients is with coronary artery calcium (CAC) scoring, which can be particularly insightful for statin decisions in borderline or intermediate risk patients. It is a far superior marker in refining risk compared to the biomarkers themselves.

The guidelines highlight some select groups of people that CAC scoring could benefit (Grundy, 2018):

  1. Patients who are reluctant to start a statin
  2. Patients who are reluctant to re-start a statin after stopping for statin-associated symptoms
  3. Older patients (men 50-88 years and women 60-80 years) with low burden of risk factors and question benefit of starting a statin
  4. Middle-aged adults (40-55 years) who fall in the “borderline” ASCVD risk category and have additional risk factors that increase their ASCVD risk

Secondary Prevention 

Secondary prevention is prevention of further ASCVD after a clinical event (like myocardial infarction, stroke, peripheral arterial or coronary revascularization) has occurred, and is a little less complicated. The two main groups in secondary prevention are “high risk” ASCVD and “stable” ASCVD. These people always get a high intensity statin right off the bat (unless the patient is > 75 years-old in which case it is a IIa recommendation to start moderate or high intensity statin).

It is about LDL goals for these people: do they achieve LDL < 70 mg/dL on a high intensity statin? If yes, then that’s awesome! If not, then we have to start thinking about adherence conversations and other medications.

Ezetimibe and PCSK9 Inhibitors

When thinking of additional medications to add to a statin for further lipid lowering events, think no further than ezetimibe and PCSK9 inhibitors! The IMPROVE-IT, as well as ODYSSEY and FOURIER trials really showed us the added benefits of ezetimibe and PCSK9 inhibitors, respectively.

High Risk ASCVD

Patients deemed as being in the “high risk” ASCVD group are those with the following:

  • Acute coronary syndrome (ACS) in the last 12 months
  • Multiple heart attacks
  • Ischemic stroke
  • Symptomatic peripheral artery disease (claudication with ABI < 0.85, or previous revascularization or amputation)
  • Age > 65 years
  • Heterozygous familial hypercholesterolemia
  • Prior coronary bypass surgery or PCI outside of the above events
  • Diabetes mellitus
  • Hypertension
  • Chronic kidney disease
  • Current smoker
  • Persistently elevated LDL > 100 mg/dL despite max statin therapy and ezetimibe
  • Congestive heart failure

These patients at “high risk” of future events require maximum-tolerated high intensity statin (Class I indication). It is a class IIa recommendation to add on ezetimibe* if LDL > 70 mg/dL while already on a high intensity statin. A PCSK9 inhibitor** can be considered either after trying a high intensity statin and ezetimibe and the LDL is still > 70 mg/dL (class I), or one can consider it after “clinically judged maximal LDL-lowering therapy” (class IIa).

*Ezetimibe from StatPearls
Article Author: Omeed Sizar                                                        Article Editor: Raja Talati Updated: 9/29/2019 2:19:18 PM
PubMed Link: Ezetimibe

**PCSK9 Inhibitor

Stable ASCVD

Patients who have established coronary disease but do not meet any of the “high risk” categories listed above fall into this group. If the patient is > 75 years old, as noted above, it is a class IIb recommendation to start either a moderate or high intensity statin. If the patient is < 75 years old, they get a high intensity statin with a goal of LDL < 70 mg/dL, or moderate intensity statin if they cannot tolerate it (Class I). If the LDL does not drop below 70 mg/dL…you guessed it! Add ezetimibe!

Follow Up and Goals

The earliest you should recheck a lipid panel after starting a statin is at 4-12 weeks (1-3 months). Afterwards, you can check anywhere from 3 to 13 months depending on the patient and their situation.

You goals are going to depend on the ASCVD risk category of your patient in primary prevention. For those in the “intermediate” category, an LDL reduction of 30-49% is appropriate. In those at high risk, however, require a reduction of LDL by > 50%. Anyone who does not meet these goals can be considered for step up in therapy.

For our secondary prevention group, you know the magic number: get that LDL < 70 mg/dL!

Is there a difference between, say for example, atorvastatin 80 mg and 40 mg? Well, yes there is! Expect to see a 50-60% reduction of LDL with atorvastatin 80 mg, and 40-52% reduction with the 40 mg.

There is no floor for LDL! The lower you can go, the better. There is no such thing as an LDL that is “too low”.

Now go on to 2020 Lipid Guidelines Review – Part 2 – Links And Excerpts From “The 2018 AHA/ACC Guideline on the Managenent of Blood Cholesterol: Executive Summary”

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