Translating the 2018 AHA/ACC, et al. 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 Guideline. 

These new guidelines differ from the most recent (2013) Cholesterol Guidelines by breaking specific sections into modular “chunks”. Our team concurs that this is an improvement, but requires the reader to doggedly read most of the 120 page guideline to find what he or she is looking for. The “chunks” include:
  • High Cholesterol & Atherosclerotic Cardiovascular Disease (ASCVD) (mostly regarding LDL cholesterol)

  • Types of Therapy (lifestyle & drugs)

  • Types of Patients (secondary prevention, severe hypercholesterolemic, diabetic, primary prevention - and by age cohort and other risk factors like ethnicity and hypertrigglyceridemia)

  • Statin Safety & AE’s

  • Cost & Value Considerations

  • Limitations & Knowledge Gaps

The Fitzpatrick Translational Science team was pleased to see that the Guideline now has “cut points” for LDL-C (at which point, for certain cohorts, recommendations are given). In the last two major guidelines (2013 Cholesterol Guidelines and 2010 Assessment of CVD Risk Guidelines), there were no cut points, so any treatment recommendations were nebulous.  The new cut points include age parameters, with most information presented for ages 40-75 and >75.

What You Need to Know (Stratify Your Population):

1. Secondary Prevention in Patients with ASCVD:
If there is an existing ASCVD event, aim for Secondary Prevention.  ASCVD consists of: acute coronary syndrome (ACS), myocardial infarction (MI), Angina, Coronary or other arterial revascularization, stroke, transient ischemic attack (TIA), peripheral artery disease (PAD), or aortic aneurysm (AA) - all of atherosclerotic origin.  Use the ASCVD Risk Predictor Plus to find ASCVD risk level. 

When ASCVD Risk is Low:
- Is the patient </=75 years?
  • If patient is on a high intensity statin and is not tolerating it, use a moderate intensity statin.

  • If LDL-C is ≥70 mg/dL, consider adding ezetimibe.

- Is the patient >75 years?  If so, use a moderate or high-intensity statin.
When ASCVD Risk is Very High:
- If the patient is on a maximal statin and LDL-C is >/=70 mg/dL, consider adding ezetimibe.
- If LDL-C is still >/= 70 (or non-HDL-C >/= 100 mg/dL), consider adding PCSK9.

Very High Risk of Future ASCVD Events:
This occurs when there is a history of multiple major ASCVD events or 1 major ASCVD event and multiple high-risk conditions.

Major ASCVD Events Include:
  • Recent ACS (within the past 12 months)

  • History of MI (other than recent ACS event listed above)

  • History of Ischemic Stroke

  • Symptomatic PAD (history of claudication with ABI <0.85, or previous revascularization or amputation)

High Risk Conditions Include:
  • Age ≥65

  • Heterozygous Familial Hypercholesterolemia

  • History of Coronary Artery Bypass Grafting (CABG) or Percutaneous Coronary Intervention (PCI), outside of major ASCVD events

  • Diabetes Mellitus

  • Hypertension

  • Chronic Kidney Disease (CKD)

  • Smoking

  • Elevated LDL-C (≥100 mg/dL)

  • History of Congestive Heart Failure (CHF)

2. Primary Prevention.
This is where it gets dicey. The guidelines can lead you down a variety of pathways. Here is how we translate it:

Learn About and Try to Lower the Patient’s ASCVD Risk:
There is a lot of emphasis on age in the Guideline. The committee seems to really only consider ages 40-75 and 75+ age groups. In other words, if someone is <40, and he/she has no familial hypercholesterolemia, hypertriglyceridemia, existing cardiovascular disease (CVD), diabetes or significant ASCVD risk, they are not too concerned.

Ages 0-19:
  • Encourage lifestyle to prevent or reduce ASCVD risk

  • Consider statin if familial hypercholesterolemia (FH) is present in family history

Ages 20-39:

  • Encourage lifestyle to reduce ASCVD risk

  • Consider statin if premature ASCVD is in the family history and LDL-C is ≥160mg/dL

Ages 40-75, non-diabetic and LDL-C is >/= 70-190 mg/dL 10-year ASCVD risk percentage:
  • <5%: Low Risk, discuss lifestyle changes to reduce risk factors

  • 5 - <7.5%: Borderline Risk, consider a moderate-intensity statin

  • ≥7.5% - <20%: Intermediate Risk, use moderate-intensity statin to reduce LDL by 30-49%

  • ≥20%: High Risk, use a statin to reduce LDL by ≥50%

Identify the Patient’s Other Risks:
  • Family history of premature ASCVD (males, age <55; females age <65)

  • Primary Hypercholesterolemia

  • Metabolic Syndrome

  • CKD

  • Other inflammatory conditions (RA, PsO, HIV/AIDS, etc.)

  • History of premature menopause

  • Ethnic Risk

  • Lipid biomarkers (i.e. hypertriglyceridemia)

3. Diabetes:
If the patient has diabetes, there are published “risk enhancers” to consider that are independent of other risk factors in type 2 diabetes to consider (we learned something new here!).  Risk enhancers include:
  • Long duration (≥10 years for type 2 diabetes or ≥20 years for type 1 diabetes)

  • Albuminuria ≥30 mcg of albumin/mg creatinine

  • eGFR <60 mL/min/1.73 m²

  • Retinopathy

  • Neuropathy

  • ABI <0.9

4. Severe Hypercholesterolemia:
If the patient has severe hypercholesterolemia (LDL >/=190 mg/dL), maximally tolerated statin therapy is recommended.

5. Share the Decision-Making with Patient/Family:
  • What is the ASCVD risk?

  • What lifestyle changes can be made?

  • What is the net benefit from drugs?

  • What are the cost considerations?

  • What is the joint plan going forward?

Much like a medical textbook, the “chunks” of content appear to be written independently, so there is a fair amount of crossover. Nonetheless, the AHA/ACC is to be commended for publishing the 2018 Guideline on the Management of Blood Cholesterol. The pieces of the cholesterol puzzle have come a lot closer together with this latest publication.

The Fitzpatrick Translational Science team has created 100’s of evidence-based medical education and risk assessment algorithms for the most prestigious medical associations and biopharma in the world. We have created cardiovascular and cardiometabolic models that include ASCVD, PAD, T2 Diabetes, Artery Age, High Blood Pressure Risk, Obesity Risk, Aortic Abdominal Aneurysm, DVT, Heart Attack, Stroke, AF to Stroke, TIA to Stroke, Heart Failure, Hyperlipidemia, Metabolic Syndrome – and others.

Kevin Fitzpatrick, Fitzpatrick Translation Science
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