Top 10 takeaways from lipid management guidelines
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CHICAGO — The 2018 Guideline on the Management of Blood Cholesterol, published by the American College of Cardiology and the American Heart Association in collaboration with other societies, offered a number of pointers for clinicians to diagnose, treat and manage patients with elevated cholesterol.
Roger S. Blumenthal, MD, FACC, FAHA, Kenneth Jay Pollin Professor of Cardiology, director of the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease and editor of the Cardiology Today Prevention section, who was a member of the writing committee for the guideline, highlighted the top 10 takeaways from this report in a presentation at the Cardiometabolic Health Congress.
Emphasize heart-healthy lifestyle
According to the presentation, a healthy lifestyle can reduce risk factor development for patients of all ages. However, for patients aged 20 to 39 years, an assessment of lifetime risk may facilitate clinician/patient discussion on working toward intensive lifestyle interventions as part of primary prevention of metabolic syndrome.
“A healthy lifestyle reduces the risk at all ages and that’s very important to prevent risk factor development,” Blumenthal said during his presentation. “When you’re less than age 40, you can assess lifetime risk. That’s very important because that emphasizes the point that lifestyle improvements can prevent the metabolic syndrome, and clearly we want to do whatever we can to prevent the development of diabetes.”
If clinical ASCVD, reduce LDL with high-intensity statin or maximum tolerated statin
The next take-home message highlighted that a greater decline in LDL provides a greater risk reduction. According to the presentation, physicians should consider using the maximally tolerated dose of statin therapy, with the goal of lowering the patient’s LDL level by at least 50%.
“If you have clinical atherosclerotic disease, you want to reduce the LDL with a high-intensity statin or the maximum tolerated dose of a statin,” Blumenthal said.
Very high-risk ASCVD: Use LDL threshold of 70 mg/dL to consider nonstatin therapy
According to the presentation, patients with multiple atherosclerosis CVD events or at least one major event with other high-risk conditions may be considered for ezetimibe alongside their maximally tolerated statin dosage.
“We classified people at very high risk if they had had a recent heart attack, stroke, acute coronary syndrome and some other high-risk conditions, and we found it was reasonable to add ezetimibe to the maximum-tolerated statin when the LDL remained above 70 mg/dL,” Blumenthal said, adding that this is based on the IMPROVE-IT trial.
Severe primary hypercholesterolemia
Additionally, Blumenthal said, should a patient present with LDL level of 190 mg/dL or more, considered severe hypercholesterolemia, ezetimibe would a reasonable treatment option depending on how low the LDL gets on high-intensity statin therapy.
“Rather than saying you always have to do genetic testing for one of the common mutations involving LDL receptors, PCSK9 or ApoB as a cause for familial hypercholesterolemia, we said if your LDL was at least 190, first begin that high-intensity statin,” Blumenthal said during his presentation. “If your LDL remained above 100, ezetimibe is reasonable to use, and then you might consider a PCSK9 inhibitor only if the statin plus ezetimibe couldn’t get you down below 100.” It is important to discuss with one’s physician whether to proceed with formal genetic testing for familial hypercholesterolemia, he added.
40 to 75 years with diabetes and LDL of at least 70 mg/dL
“For diabetes we said that if you’re 40 to 75 years old and have diabetes and an LDL at least 70, you want to begin a moderate-intensity statin,” Blumenthal said. “For older individuals that are above the age of 50, they are more likely to have a higher ASCVD risk and more risk factors. They may qualify for a high-intensity statin.”
40 to 75 years evaluated for primary prevention
Clinicians should have a discussion with their 40- to 75-year-old patients that includes their estimated 10-year risk, major risk factors, lifestyle changes, anticipated benefits of statin therapy, potential adverse effects, drug interactions and cost.
“The guiding factor was patient preferences and their values,” Blumenthal said during his presentation. “Some people who may have a family history of heart disease or know someone who’s had an early cardiovascular event, and they’d be much more apt to want to go on a statin than those individuals who have never had a friend or a family member have a CV event.”
40 to 75 years without diabetes, LDL at least 70 mg/dL and 10-year risk of at least 7.5%
Another recommendation in the guideline stated that if a clinician is unable to determine risk status of a patient aged 40 to 75 years without diabetes, an LDL at least 70 mg/dL and 10-year risk of at least 7.5%, they might consider coronary artery calcium scoring to resolve this uncertainty. If a person has a family history of premature ASCVD, a CAC scan could be considered at a 5% 10-year risk level.
“With these patients, we should at least start a moderate-intensity statin if that’s what the risk discussion favors,” Blumenthal said. “We could use risk-enhancing factors and could consider a coronary artery calcium scan as basically a tiebreaker in trying to decide what a patient should do.”
40 to 75 years without diabetes and 10-year risk of 7.5% to 19.9%
For intermediate-risk individuals who fall between the low-risk and high-risk classifications for ASCVD, the guidelines suggest analyzing risk-enhancing factors that include:
- history of premature menopause (less than 40 years) or pregnancy-associated conditions such as preeclampsia;
- high-risk race or ethnicity such as South Asian;
- lipids or biomarkers associated with increased ASCVD risk; and
- primary hypertriglyceridemia (≥ 175 mg/dL, nonfasting).
“In addition, we brought chronic kidney disease back into the U.S. guidelines,” Blumenthal said during his presentation. “We also added chronic inflammatory conditions, something that wasn’t in prior guidelines. This includes advanced psoriasis, rheumatoid arthritis, lupus and HIV.”
40 to 75 years without diabetes, LDL at least 70 mg/dL and intermediate ASCVD risk, if statin decision uncertain
Blumenthal stated that if the statin decision is still unresolved in an intermediate-risk population, a clinician should again consider a CAC scan:
- If CAC is 0, statin may be withheld or delayed, except in smokers, those with diabetes or those with a very strong family history of premature ASCVD.
- If CAC is 1 to 99, statin therapy is reasonable to consider.
- If CAC is 100 or greater, statin use is indicated.
Repeat measurements
According to the presentation, clinicians should define response to intensive lifestyle intervention and statin therapy by percentage change in LDL compared with baseline.
In addition, Blumenthal added that patients with very high risk ASCVD and LDL 70 mg/dL or more on maximally tolerated statin therapy should be considered for a nonstatin medication.
“We wanted to remind people they needed to recheck the lipids,” Blumenthal said. “We wanted to assess adherence, the response to LDL-lowering therapy plus the lifestyle changes; once we started on a medication or made a dose titration it was important to recheck lipids anywhere in that 8-to-12-week mark. If lipid values were right where you wanted then, you might delay another lipid panel for 6 to 12 months.” – by Scott Buzby
References:
Blumenthal RS. Guideline and Gaps in Lipid Management. Presented at: Cardiometabolic Health Congress; Oct. 10-13, 2019; Chicago.
Grundy SM, et al. J Am Coll Cardiol. 2018; doi:10.1016/j.jacc.2018.11.003.
Disclosure: Blumenthal reports no relevant financial disclosures.