Hyperlipidemias and Atherosclerotic Cardiovascular Disease ________________________________________
AHA/ACC RECOMMENDATIONS FOR STATIN THERAPY
Age
Patient Factors
Recommendation
Target % LDL
Patients with Diabetes 40 to 75 years Diabetes
Moderate-intensity statin, regardless of estimated 10-year ASCVD risk
—
Diabetes and LDL 70–189 mg/dL
Reasonable to assess 10-year risk of first ASCVD event using race-, sex-specific pooled cohort equations — Reasonable to prescribe high-intensity statin ≥50%
Diabetes with multiple ASCVD risk factors
≥75 years Diabetes and on statin therapy
Reasonable to continue statin therapy Diabetes and 10-year ASCVD risk ≥20% May be reasonable to add ezetimibe to maximally tolerated statin
≥50%
>75 years Diabetes
May be reasonable to initiate statin therapy after clinician-patient risk discussion
—
Diabetes with specific risk enhancers a
20 to 39 years
May be reasonable to initiate statin therapy —
Patients with No Diabetes But Other Risk Factors 40 to 75 years LDL ≥70 mg/dL and 10-year ASCVD risk ≥7.5%
Moderate-intensity statin, if favored by clinician-patient risk discussion
—
a Diabetes of long duration (≥10 years type 2, ≥20 years type 1), albuminuria, eGFR <60 mL/min/1.73 m 2 , retinopathy, neuropathy, ankle-brachial index <0.9 Source: [24] Table 9
In addition to the patient factors discussed, race and ethnicity inform and influence the estimates of ASCVD risk, treatment intensity, use of lipids, and other issues. For example, when evaluating ASCVD risk, it is useful for the clinician to know that risk in people of South and East Asian origin varies by country of origin. When evaluating lipid issues, it is useful to know that Hispanic/Latina women have a higher prevalence of low HDL compared with Hispanic/Latino men. When evaluating metabolic issues, it is useful to know that there is an increased prevalence of diabetes and hypertension among Black Americans. Country-specific race/ethnicity, along with the patient’s socioeconomic status, may affect the estimation of risk by pooled cohort equations [24]. Other at-risk patient groups include those with moderate or severe hypertriglyceridemia, women with gender-specific history (e.g., premature menopause, history of pregnancy- associated disorders), adults with chronic kidney disease, adults with chronic inflammatory disorders and HIV, older adults (≥75 years of age), young adults (20 to 39 years of age), and children and adolescents. The 2018 AHA/ACC guideline provides recommendations and considerations for clinical decision-making for these unique patient populations [24]. Additionally, the guideline continues to emphasize adherence to a heart-healthy lifestyle from adolescence onward; promote assessment of lifetime ASCVD risk for young adults 20 to 40 years of age; and emphasize comprehensive lifestyle improvements to prevent development of metabolic syndrome [231].
Adherence to changes in lifestyle and effects of LDL-lowering medication should be assessed by measuring fasting lipids 4 to 12 weeks after initiation of statin therapy or dose adjustment, and every 3 to 12 months thereafter to assess adherence and safety indicators. Good adherence to an LDL-lowering diet will reduce LDL levels by 10% to 15%. Moderate-intensity statins may reduce LDL levels by another 30% to 40%, and high-intensity statins by ≥50%. The intensity of statin therapy will vary according to the patient’s age and risk category [24]. CONCLUSION Cardiovascular diseases are a leading cause of death in developed countries. Although the prevalence of ASCVD in developed countries has increased in the past 40 years, the mortality rate has declined as the result of advances in diagnosis and medical and surgical treatments. The complex interaction between modifiable, non-modifiable, and risk-enhancing risk factors underlies the etiology of ASCVD. It is now well established that hyperlipidemias, and high concentrations of LDL in particular, are implicated in the etiology of atherosclerosis and increased incidence of ASCVD such as coronary artery disease, peripheral vascular disease, and ischemic cerebrovascular disease. Hyperlipidemias are also associated with primary hypertension and metabolic syndrome. As a result, prevention, early diagnosis, and appropriate clinical management of hyperlipidemias have become a public health priority.
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