on the Management of Blood Cholesterol
Primary Prevention
Scott M. Grundy, MD, PhD1; Neil J. Stone, MD2
Author Affiliations Article Information
JAMA Cardiol. 2019;4(5):488-489. doi:10.1001/jamacardio.2019.0777
related articles icon Related
Articles
Guideline title: 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol
Developers: American College of Cardiology (ACC) and American Heart Association (AHA)
Release date: November 10, 2018
Prior version: November 12, 2013
Funding sources: ACC and AHA
Target population: Individuals at risk for atherosclerotic cardiovascular disease
Major recommendations
In all individuals, emphasize heart-healthy lifestyle across the life course.
In patients with severe primary hypercholesterolemia (low-density lipoprotein cholesterol [LDL-C] ≥190 mg/dL [to convert to millimoles per liter, multiply by 0.0259], without calculating 10-year atherosclerotic cardiovascular disease (ASCVD) risk, begin high-intensity statin therapy. Consider adding nonstatins if LDL-C level while receiving statin therapy is 100 mg/dL or higher.
In patients with diabetes mellitus aged 40 to 75 years with an LDL-C level of 70 mg/dL or higher, start taking moderate-intensity statins without calculating 10-year ASCVD risk. As risk increases with age and risk factors, high-intensity statin therapy is reasonable.
In adults evaluated for primary ASCVD prevention, have a patient-clinician risk discussion before starting statin therapy.
In adults aged 40 to 75 years without diabetes and LDL-C level of 70 mg/dL or higher at a 10-year ASCVD risk of 7.5% or higher, start a moderate-intensity statin if a discussion of treatment options favors statin therapy.
In adults aged 40 to 75 years without diabetes mellitus and 10-year risk of 7.5% to 19.9% (intermediate risk), risk-enhancing factors favor initiation of statin therapy.
In adults aged 40 to 75 years without diabetes mellitus and with LDL-C levels of 70 mg/dL to 189 mg/dL at a 10-year ASCVD risk of 7.5% to 19.9%, if a decision about statin is uncertain, consider measuring coronary artery calcium.
Assess adherence and percentage response to LDL-C–lowering medications and lifestyle changes with repeat lipid measurement 4 to 12 weeks after statin initiation or dose adjustment and every 3 to 12 months as needed.
Summary of Clinical Problem
Atherosclerotic cardiovascular disease (ASCVD) is the most common cause of death in the United States.1 Elevated low-density lipoprotein cholesterol (LDL-C) level is a major risk factor for ASCVD. Randomized clinical trials of patients without ASCVD demonstrate that lowering LDL-C levels reduces risk for future cardiovascular events. Statins are primary drugs for reducing LDL-C levels. This document reviews evidence-based strategies to reduce LDL-C levels in primary prevention.
Characteristics of Guidelines Source
This guideline was developed by the American College of Cardiology (ACC), American Heart Association (AHA), and collaborating organizations (American Association of Cardiovascular and Pulmonary Rehabilitation, American Association Academy of Physician Assistants, Association of Black Cardiologists, American College of Preventive Medicine, American Diabetes Association, American Geriatrics Society, American Pharmacists Association, American Society for Preventive Cardiology, National Lipid Association, and Preventive Cardiovascular Nurses Association).1
Evidence Base
The development of recommendations was based on all available evidence, with the literature search of randomized clinical trials, registries, nonrandomized comparative and descriptive studies, and systematic reviews. Class of recommendation and level of evidence are based on ACC/AHA criteria. The chairs and other writing committee members had no relevant relations with industry.
Discussion
The strategy for primary prevention is outlined in the Figure. The guideline emphasizes a heart-healthy lifestyle throughout life, and depending on a patient’s risk status, judicious use of statin therapy. As a practical measure, the guidelines allow use of nonfasting lipids for screening.
In patients with hypercholesterolemia and midlife diabetes at age 40 to 75 years, risk is high enough to support statin treatment without need for quantitative risk assessment. In other adults aged 40 to 75 years, the guidelines offer 3 steps in selection of statin therapy. A patient-clinician risk discussion is necessary at each of the steps. The first step is to estimate 10-year ASCVD risk using the AHA/ACC risk calculator. This calculator includes major ASCVD risk factors and triages risk into low risk (0%-5%), borderline risk (5%-7.5%), intermediate risk (7.5%-20%), and high risk (>20%). The second step is to identify risk-enhancing factors. These are stable factors that associate with ASCVD beyond those incorporated in the risk calculator. As a third step, if risk remains uncertain, the clinician has the option to measure coronary artery calcium (CAC) levels to assist in the decision whether to initiate statin therapy.
Enhancing factors include family history of premature ASCVD; persistently elevated LDL-C levels of 160 mg/dL or higher (to convert to millimoles per liter, multiple by 0.0259), metabolic syndrome, chronic kidney disease, history of preeclampsia or premature menopause (younger than 40 years), chronic inflammatory disorders (eg, rheumatoid arthritis, psoriasis, chronic HIV), ethnic groups at high risk (eg, South Asian); persistent elevations of triglyceride level of 175 mg/dL or higher (to convert to millimoles per liter, multiply by 0.0113), and, if measured in selected individuals, apolipoprotein B of 130 mg/dL or higher (to convert to grams per liter, multiply by 0.01), high-sensitivity C-reactive protein of 2.0 mg/L or higher (to convert to nanomoles per liter, multiply by 9.524), ankle-brachial index less than 0.9, and lipoprotein(a) level of 50 mg/dL higher (to convert to micromole per liter, multiply by 0.0357). Patients with borderline risk are potential candidates for statin therapy, but the presence of risk-enhancing factors may underpin a decision to initiate statins. Patients at intermediate risk are in a statin-efficacy zone.
The presence of risk-enhancing factors in intermediate-risk patients favors statin therapy. Most high-risk patients (>20% 10-year risk) should start receiving a statin, preferably, a high-intensity statin.
If risk remains uncertain after the first 2 steps, measurement of CAC in intermediate-risk patients can guide in the decision to initiate statin therapy. Zero CAC level allows delay of statins except in smokers, those with diabetes, or in individuals with a family history of premature ASCVD. A CAC score of 1 to 99 Agatston units favors statin therapy in patients 55 years or older, whereas a score of 100 or more or 75th percentile or higher supports statin use in most patients.
Areas in Need of Future Study or Ongoing Research
Future or ongoing research should include continuing refinement of the pooled cohort equations, improvement in lifetime risk estimate, refinement of the patient-clinician risk discussion including the entire process of decision making and long-term follow-up, and prognostic significance of CAC including when and in whom follow-up measurements of CAC should be done to reassess risk status.
Related guidelines and other resources
Calcium score calculator
Management of blood cholesterol
Back to top
Article Information
Corresponding Author: Neil J. Stone, MD, Northwestern University Feinberg School of Medicine, 676 N St Clair St, #600, Chicago, IL 60611 (n-stone@northwestern.edu).
Published Online: April 10, 2019. doi:10.1001/jamacardio.2019.0777
Conflict of Interest Disclosures: None reported.
References
1.
Grundy SM, Stone NJ, Bailey AL, et al 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published online November 3, 2018]. J Am Coll Cardiol. doi:10.1016/j.jacc.2018.11.003Google Scholar
Primary Prevention
Scott M. Grundy, MD, PhD1; Neil J. Stone, MD2
Author Affiliations Article Information
JAMA Cardiol. 2019;4(5):488-489. doi:10.1001/jamacardio.2019.0777
related articles icon Related
Articles
Guideline title: 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol
Developers: American College of Cardiology (ACC) and American Heart Association (AHA)
Release date: November 10, 2018
Prior version: November 12, 2013
Funding sources: ACC and AHA
Target population: Individuals at risk for atherosclerotic cardiovascular disease
Major recommendations
In all individuals, emphasize heart-healthy lifestyle across the life course.
In patients with severe primary hypercholesterolemia (low-density lipoprotein cholesterol [LDL-C] ≥190 mg/dL [to convert to millimoles per liter, multiply by 0.0259], without calculating 10-year atherosclerotic cardiovascular disease (ASCVD) risk, begin high-intensity statin therapy. Consider adding nonstatins if LDL-C level while receiving statin therapy is 100 mg/dL or higher.
In patients with diabetes mellitus aged 40 to 75 years with an LDL-C level of 70 mg/dL or higher, start taking moderate-intensity statins without calculating 10-year ASCVD risk. As risk increases with age and risk factors, high-intensity statin therapy is reasonable.
In adults evaluated for primary ASCVD prevention, have a patient-clinician risk discussion before starting statin therapy.
In adults aged 40 to 75 years without diabetes and LDL-C level of 70 mg/dL or higher at a 10-year ASCVD risk of 7.5% or higher, start a moderate-intensity statin if a discussion of treatment options favors statin therapy.
In adults aged 40 to 75 years without diabetes mellitus and 10-year risk of 7.5% to 19.9% (intermediate risk), risk-enhancing factors favor initiation of statin therapy.
In adults aged 40 to 75 years without diabetes mellitus and with LDL-C levels of 70 mg/dL to 189 mg/dL at a 10-year ASCVD risk of 7.5% to 19.9%, if a decision about statin is uncertain, consider measuring coronary artery calcium.
Assess adherence and percentage response to LDL-C–lowering medications and lifestyle changes with repeat lipid measurement 4 to 12 weeks after statin initiation or dose adjustment and every 3 to 12 months as needed.
Summary of Clinical Problem
Atherosclerotic cardiovascular disease (ASCVD) is the most common cause of death in the United States.1 Elevated low-density lipoprotein cholesterol (LDL-C) level is a major risk factor for ASCVD. Randomized clinical trials of patients without ASCVD demonstrate that lowering LDL-C levels reduces risk for future cardiovascular events. Statins are primary drugs for reducing LDL-C levels. This document reviews evidence-based strategies to reduce LDL-C levels in primary prevention.
Characteristics of Guidelines Source
This guideline was developed by the American College of Cardiology (ACC), American Heart Association (AHA), and collaborating organizations (American Association of Cardiovascular and Pulmonary Rehabilitation, American Association Academy of Physician Assistants, Association of Black Cardiologists, American College of Preventive Medicine, American Diabetes Association, American Geriatrics Society, American Pharmacists Association, American Society for Preventive Cardiology, National Lipid Association, and Preventive Cardiovascular Nurses Association).1
Evidence Base
The development of recommendations was based on all available evidence, with the literature search of randomized clinical trials, registries, nonrandomized comparative and descriptive studies, and systematic reviews. Class of recommendation and level of evidence are based on ACC/AHA criteria. The chairs and other writing committee members had no relevant relations with industry.
Discussion
The strategy for primary prevention is outlined in the Figure. The guideline emphasizes a heart-healthy lifestyle throughout life, and depending on a patient’s risk status, judicious use of statin therapy. As a practical measure, the guidelines allow use of nonfasting lipids for screening.
In patients with hypercholesterolemia and midlife diabetes at age 40 to 75 years, risk is high enough to support statin treatment without need for quantitative risk assessment. In other adults aged 40 to 75 years, the guidelines offer 3 steps in selection of statin therapy. A patient-clinician risk discussion is necessary at each of the steps. The first step is to estimate 10-year ASCVD risk using the AHA/ACC risk calculator. This calculator includes major ASCVD risk factors and triages risk into low risk (0%-5%), borderline risk (5%-7.5%), intermediate risk (7.5%-20%), and high risk (>20%). The second step is to identify risk-enhancing factors. These are stable factors that associate with ASCVD beyond those incorporated in the risk calculator. As a third step, if risk remains uncertain, the clinician has the option to measure coronary artery calcium (CAC) levels to assist in the decision whether to initiate statin therapy.
Enhancing factors include family history of premature ASCVD; persistently elevated LDL-C levels of 160 mg/dL or higher (to convert to millimoles per liter, multiple by 0.0259), metabolic syndrome, chronic kidney disease, history of preeclampsia or premature menopause (younger than 40 years), chronic inflammatory disorders (eg, rheumatoid arthritis, psoriasis, chronic HIV), ethnic groups at high risk (eg, South Asian); persistent elevations of triglyceride level of 175 mg/dL or higher (to convert to millimoles per liter, multiply by 0.0113), and, if measured in selected individuals, apolipoprotein B of 130 mg/dL or higher (to convert to grams per liter, multiply by 0.01), high-sensitivity C-reactive protein of 2.0 mg/L or higher (to convert to nanomoles per liter, multiply by 9.524), ankle-brachial index less than 0.9, and lipoprotein(a) level of 50 mg/dL higher (to convert to micromole per liter, multiply by 0.0357). Patients with borderline risk are potential candidates for statin therapy, but the presence of risk-enhancing factors may underpin a decision to initiate statins. Patients at intermediate risk are in a statin-efficacy zone.
The presence of risk-enhancing factors in intermediate-risk patients favors statin therapy. Most high-risk patients (>20% 10-year risk) should start receiving a statin, preferably, a high-intensity statin.
If risk remains uncertain after the first 2 steps, measurement of CAC in intermediate-risk patients can guide in the decision to initiate statin therapy. Zero CAC level allows delay of statins except in smokers, those with diabetes, or in individuals with a family history of premature ASCVD. A CAC score of 1 to 99 Agatston units favors statin therapy in patients 55 years or older, whereas a score of 100 or more or 75th percentile or higher supports statin use in most patients.
Areas in Need of Future Study or Ongoing Research
Future or ongoing research should include continuing refinement of the pooled cohort equations, improvement in lifetime risk estimate, refinement of the patient-clinician risk discussion including the entire process of decision making and long-term follow-up, and prognostic significance of CAC including when and in whom follow-up measurements of CAC should be done to reassess risk status.
Related guidelines and other resources
Calcium score calculator
Management of blood cholesterol
Back to top
Article Information
Corresponding Author: Neil J. Stone, MD, Northwestern University Feinberg School of Medicine, 676 N St Clair St, #600, Chicago, IL 60611 (n-stone@northwestern.edu).
Published Online: April 10, 2019. doi:10.1001/jamacardio.2019.0777
Conflict of Interest Disclosures: None reported.
References
1.
Grundy SM, Stone NJ, Bailey AL, et al 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published online November 3, 2018]. J Am Coll Cardiol. doi:10.1016/j.jacc.2018.11.003Google Scholar
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