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

These are my three posts on recent Lipid Guidelines:

Here are the links to and excerpts from 2018 AHA/ACC Guideline on the Management of Blood Cholesterol: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [PubMed Abstract] [Full Text HTML] [Download Full Text PDF]. J Am Coll Cardiol. 2019 Jun 25;73(24):3168-3209. doi: 10.1016/j.jacc.2018.11.002. Epub 2018 Nov 10:


1. In all individuals, emphasize a heart-healthy lifestyle
across the life course. A healthy lifestyle reduces
atherosclerotic cardiovascular disease (ASCVD) risk at
all ages. In younger individuals, healthy lifestyle can reduce development of risk factors and is the foundation of ASCVD risk reduction. In young adults 20 to 39 years of age, an assessment of lifetime risk facilitates the clinician–patient risk discussion (see No. 6) and emphasizes intensive lifestyle efforts. In all age
groups, lifestyle therapy is the primary intervention for metabolic syndrome.

2. In patients with clinical ASCVD, reduce low-density
lipoprotein cholesterol (LDL-C) with high-intensity statin therapy or maximally tolerated statin therapy. The more LDL-C is reduced on statin therapy, the greater will be subsequent risk reduction. Use a maximally tolerated statin to lower LDL-C levels by >50%.

3. In very high-risk ASCVD, use a LDL-C threshold of 70 mg/dL (1.8 mmol/L) to consider addition of nonstatins to statin therapy. Very high-risk includes a history of multiple major ASCVD events or 1 major ASCVD event and multiple high-risk conditions. In very high-risk ASCVD patients, it is reasonable to add ezetimibe to maximally tolerated statin therapy when
the LDL-C level remains >70 mg/dL (>1.8 mmol/L). In patients at very high risk whose LDL-C level remains >70 mg/dL (>1.8 mmol/L) on maximally tolerated statin and ezetimibe therapy, adding a PCSK9 inhibitor is reasonable, although the long-term
safety (>3 years) is uncertain and cost effectiveness is low at mid-2018 list prices.

4. In patients with severe primary hypercholesterolemia (LDL-C level ‡190 mg/dL [‡4.9 mmol/L]), without calculating 10-year ASCVD risk, begin high-intensity statin therapy. If the LDL-C level remains >100 mg/dL
(>2.6 mmol/L), adding ezetimibe is reasonable. If the
LDL-C level on statin plus ezetimibe remains >100
mg/dL (>2.6 mmol/L) and the patient has multiple
factors that increase subsequent risk of ASCVD events,
a PCSK9 inhibitor may be considered, although the
long-term safety (>3 years) is uncertain and economic
value is low at mid-2018 list prices.

5. In patients 40 to 75 years of age with diabetes mellitus and LDL-C ‡70 mg/dL (‡1.8 mmol/L), start moderate-intensity statin therapy without calculating 10-year ASCVD risk. In patients with diabetes mellitus at higher risk, especially those with multiple risk factors or those 50 to 75 years of age, it is reasonable to use a high-intensity statin to reduce the LDL-C level by >50%.

6. In adults 40 to 75 years of age evaluated for primary
ASCVD prevention, have a clinician–patient risk discussion before starting statin therapy. Risk discussion should include a review of major risk factors (e.g., cigarette smoking, elevated blood pressure, LDL-C, hemoglobin A1C [if indicated], and calculated 10-year risk of ASCVD); the presence of risk-enhancing factors (see No. 8); the potential benefits of lifestyle and statin therapies; the potential for adverse effects
and drug–drug interactions; consideration of costs of statin therapy; and patient preferences and values in shared decision-making.

7. In adults 40 to 75 years of age without diabetes
mellitus and with LDL-C levels >/=70 mg/dL (>/=1.8 mmol/L), at a 10-year ASCVD risk of >/=7.5%, start a
moderate-intensity statin if a discussion of treatment
options favors statin therapy. Risk-enhancing factors favor statin therapy (see No. 8). If risk status is uncertain, consider using coronary artery calcium (CAC) to improve specificity (see No. 9). If statins are indicated, reduce LDL-C levels by >30%, and if 10-year risk is >20%, reduce LDL-C levels by >50%.

8. In adults 40 to 75 years of age without diabetes
mellitus and 10-year risk of 7.5% to 19.9% (intermediate risk), risk-enhancing factors favor initiation of statin therapy (see No. 7). Risk-enhancing factors include family history of premature ASCVD; persistently
elevated LDL-C levels >/=160 mg/dL (>/=4.1 mmol/L);
metabolic syndrome; chronic kidney disease; history of
preeclampsia or premature menopause (age <40 years); chronic inflammatory disorders (e.g., rheumatoid arthritis, psoriasis, or chronic HIV); high-risk ethnic groups (e.g., South Asian); persistent elevations of triglycerides >/=175 mg/dL (>/=1.97 mmol/L); and, if measured in selected individuals, apolipoprotein B >/=130 mg/dL, high-sensitivity C-reactive protein >/=2.0 mg/L, ankle-brachial index (ABI) <0.9 and lipoprotein (a) >/=50 mg/dL or 125 nmol/L, especially at higher values of lipoprotein (a). Risk-enhancing factors may favor statin therapy in patients at 10-year risk of 5% to 7.5% (borderline risk).

9. In adults 40 to 75 years of age without diabetes
mellitus and with LDL-C levels >/=70 mg/dL to 189 mg/dL (>/=1.8–4.9 mmol/L), at a 10-year ASCVD
risk of >/=7.5% to 19.9%, if a decision about statin
therapy is uncertain, consider measuring CAC. If CAC is zero, treatment with statin therapy may be withheld or delayed, except in cigarette smokers, those with diabetes mellitus, and those with a strong family history of premature ASCVD. A CAC score of 1 to 99 favors statin therapy, especially in those $55
years of age. For any patient, if the CAC score is >/=100
Agatston units or >/=75th percentile, statin therapy is indicated unless otherwise deferred by the outcome of clinician–patient risk discussion.

10. 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. Define responses to lifestyle and statin therapy by percentage reductions in LDL-C levels compared with baseline. In ASCVD patients at very high-risk, triggers for adding nonstatin drug therapy are defined by threshold LDL-C levels >/=70 mg/dL (>/=1.8 mmol/L) on maximal statin therapy (see No. 3).






Primary Prevention


See the Complete Executive Summary for all the charts and figures.

And now go to 2020 Lipid Guidelines Review – Part 3 – Links And Excerpts From “The 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk”

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