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2018 cholesterol clinical practice guidelines: what PCPs need to know
A synopsis of the 2018 Guideline on the Management of Blood Cholesterol by the American Heart Association, American College of Cardiology and other societies that focused on clinical practice PCPs was recently published in the Annals of Internal Medicine.
“Guidelines urge emphasis on lifestyle over the life course starting in childhood,” Neil J. Stone, MD, of Northwestern University Feinberg School of Medicine, told Healio Primary Care. “Attention to heart-healthy lifestyles can prevent risk factors later on and also reduce the need for statins therapy later in life.”
The guidelines were updated after a panel of experts conducted systematic reviews and meta-analyses of randomized clinical trials that evaluated cardiovascular outcomes. The panel reviewed results from the trials to determine the benefits and detriments of nonstatin medication use with statin therapy compared with statin therapy alone in patients at high risk for developing atherosclerotic cardiovascular disease, or ASCVD.
New screening guidelines indicated that nonfasting and fasting lipid profiles were effective in estimating ASCVD risk and determining baseline LDL-C levels.
New secondary preventions in the guidelines included separating patients into high-risk and very high-risk groups. Patients at very high risk for ASCVD had a history of multiple major ASCVD events or one major ASCVD event in addition to multiple other high-risk conditions.
"Three randomized controlled trials new since the 2013 cholesterol guidelines showed that both ezetimibe and the PCSK9 inhibitors alirocumab and evolocumab reduce rates of heart attack and stroke on top of statins in those at very high risk of ASCVD events,” Stone said. “Guidelines recommend a threshold of LDL-C of 70 mg/dL to consider addition of nonstatins to maximally tolerated statin therapy in those at very high risk.”
The guidelines emphasized that those with an LDL-C level of 190 mg/dL or greater in early life and adults aged 40 to 75 years with diabetes would benefit from statin therapy. Another group, adults aged 40 to 75 years who did not have diabetes, should undergo risk assessment before statin therapy is initiated.
Stone explained that the guidelines recommend clinicians discuss risks with patients before initiating statin therapy. The guidelines identified 10-year ASCVD risk estimation as the first component of risk discussion, followed by the evaluation of risk-enhancing factors including family history of premature ASCVD and persistently elevated LDL-C levels. If risk decision remained uncertain, the guidelines recommend the use of coronary artery calcium testing.
The guidelines should have immediate impact on clinical practice, Stone said.
“For those who see patients in the afternoon, the ability to order nonfasting lipids for screening helps clinical labs and patients alike,” he said. “For secondary prevention, there are numbers (LDL-C threshold = 70 mg/dL) to help guide more aggressive LDL-C-lowering therapy. For primary prevention, the clinician-patient discussion has more tools to help direct statin therapy to those who would benefit most.”– by Erin Michael
Disclosures: The authors report no relevant financial disclosures.