Hyperlipidemias and Atherosclerotic Cardiovascular Disease ________________________________________
The 2018 and 2019 AHA/ACC guidelines concur with the recommendation that clinical management should be based on calculation of the patient’s 10-year estimated risk of ASCVD, as this will influence the intensity of management, whether it be lifestyle modification, drug therapy, or both [24; 236]. In children, adolescents, and young adults, priority should be estimation of lifetime risk and promotion of lifestyle risk reduction [24]. The ACC ASCVD risk assessment tool is available (http://tools.acc.org/ASCVD-Risk-Estimator-Plus) to estimate the risk of ASCVD within 10 years. The risk calculator is intended for use in patients 40 to 75 years of age who do not have diabetes and whose LDL cholesterol is 70–189 mg/dL [235]. The AHA/ACC recommends that for adults 40 to 70 years of age, clinicians routinely assess traditional risk factors and calculate the estimated 10-year risk of ASCVD [24; 236]. For adults 20 to 39 years of age, clinicians should assess (monitor) ASCVD risk factor status every three to six years. For adults at borderline risk (5% to <7.5% 10-year ASCVD risk) or intermediate risk (7.5% to <20% 10-year ASCVD risk), additional risk-enhancing factors can be used to guide decisions about therapeutic interventions; such factors may include family history of premature ASCVD, chronic inflammatory disease (e.g., rheumatoid arthritis, lupus), chronic kidney disease, early menopause, or metabolic syndrome. In adults at intermediate risk or borderline 10-year ASCVD risk, if risk- based decisions for preventive therapy such as statin treatment remain uncertain, it is reasonable to measure a coronary artery calcium score to guide clinician-patient risk discussion [236]. For purposes of shared clinical decision making, the AHA/ ACC categorizes patients according to level of cardiovascular disease risk at 10 years and recommends routine clinician- patient ASCVD risk discussion in relation to the level of risk [24; 236]: • Low (<5%): Risk discussion should emphasize healthy lifestyle to reduce risk. • Borderline (5% to <7.5%): If there are risk enhancers present, then risk discussion regarding benefit of moderate-intensity statin therapy. • Intermediate (7.5% to <20%): If risk estimate plus added risk enhancers favor statin therapy, discussion on benefit of initiating moderate-intensity statin to reduce LDL-C by 30% to 49%. • High (≥20%): Discussion on benefit of statin
Two higher-risk patient categories are those with severe hypercholesterolemia (LDL ≥190 mg/dL) and older adults with diabetes. Patients with severe hypercholesterolemia and adults 40 to 75 years of age with diabetes are candidates for immediate statin therapy without further risk assessment. Adults with diabetes should start with a moderate-intensity statin (i.e., one that lowers LDL by 30% to 49%). A high-intensity statin (i.e., one that lowers LDL by ≥50%) may be indicated as the patient accrues multiple risk factors. In all other adults 40 to 75 years of age, the 10-year risk of ASCVD should guide therapeutic decision making. The higher the 10-year risk, the more likely the patient will benefit from evidence-based statin treatment [24]. CLINICAL GUIDELINES FOR THE TREATMENT OF HYPERLIPIDEMIAS Treatment guidelines for hyperlipidemias were developed by the NCEP-ATP III [230]. These guidelines were partially updated by the 2013 ACC/AHA guideline; however, as discussed, the recommendations provided by the 2018 AHA/ ACC guideline and adapted by the 2019 AHA/ACC guideline on primary prevention of CVD will be presented [24; 236]. In 2020, the Department of Veterans Affairs and the Department of Defense (VA/DoD) also published a clinical practice guideline for the management of dyslipidemia [237]. The VA/DoD guideline is designed for the adult population older than 40 years of age and eligible for healthcare in the VA and DoD health systems. Healthcare professionals working within the VA and DoD systems, and others participating in care of patients within the systems, may wish to review the VA/DoD document, as there are differences between these guidelines and the AHA/ACC guidelines, such as the intensity of statin recommended, the risk level thresholds for statin treatment, and the use of adjunctive therapies for primary prevention in patients on statins [238]. Guidelines on management of hyperlipidemia specify four major categories of patients for whom statins may be considered ( Table 9 ) [24]: • Those with clinical ASCVD • Those with severe hypercholesterolemia (LDL ≥190 mg/dL) • Those 40 to 75 years of age with diabetes and LDL ≥70 mg/dL • Those 40 to 75 years of age with no diabetes but with LDL ≥70 mg/dL and ≥7.5% 10-year ASCVD risk
therapy to reduce LDL-C by 50% or more combined with adoption of a healthy lifestyle.
A 10-year “intermediate” risk score (10% to 15%) does not automatically mandate a statin, but rather should lead to discussion and shared decision-making between the clinician and the patient [229]. Drug therapy is recommended only in select patients with moderately-high LDL (≥160 mg/dL) or patients with very-high LDL (190 mg/dL).
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