ACC/AHA Multisociety Guideline: Cholesterol Assessment and Primary ASCVD Prevention

SUMMARY:

2018/2019 ACC/AHA Multisociety Guideline on the Management of Blood Cholesterol provides recommendations for the evaluation and prevention of ASCVD. The ‘ASCVD Risk Estimator Plus for Primary Prevention’ link is provided in the ‘Learn More – Primary Sources’ section below.

Algorithm Assessment for Primary Prevention (age 40-75)

Risk Enhancers

Statin Therapy

Statin Side Effects

USPSTF and Statin Use

Algorithm Assessment for Primary Prevention (age 40 to 75)

Non-Diabetic

LDL-C: <70 mg/dL

Assess lifetime risk

LDL-C: 70 to189 mg/dL

High Risk: 10-year risk ≥20%
- High intensity statin
  - Aim for LDL-C lowering ≥50%
Intermediate Risk: 10-year risk ≥7.5% to <20%
- ‘Risk Enhancers’ (see ‘Key Points’ below) favor starting statin therapy
- Consider coronary artery calcium (CAC) score if statin decision uncertain
  - 0 score: Lowers risk (consider no statin, especially nonsmoker without family history of premature CHD)
  - 1 to 99 score: Favors statin (especially > 55 years)
  - 100+ score and/or ≥75th percentile: Initiate statin therapy
- Moderate intensity statin
  - Aim for LDL-C lowering 30 to 50%
Borderline Risk: 10-year risk 5 to <7.5%
- Initiate risk discussion regarding statin benefits based on risk enhancers
- Lifestyle changes
- Selective moderate statin
Low Risk: 10-year risk <5%
- Lifestyle and risk discussion (Diet, physical activity, weight/BMI, tobacco use)

LDL-C: ≥190 mg/dL (primary severe hypercholesterolemia)

Maximum tolerated statin is recommended
- If LDL-C ≥100 mg/dL: Adding ezetimibe is reasonable
- PCSK9 inhibitor may be considered in circumstances where LDL-C baseline is very high (≥220 mg/dL) and levels remain elevated (≥130 mg/dL) despite statins and ezetimibe

Diabetic Patient

LDL-C: 70 to 189 mg/dL

Moderate intensity statin
- Aim for LDL-C lowering 30 to 50%
High intensity statin
- If Multiple ASCVD risk factors and 50 to 75 y of age
Diabetes-specific risk enhancers
- Long duration (≥10 years for type 2 diabetes or ≥ 20 years for type 1 diabetes)
- Albuminuria ≥30 mcg albumin/mg creatinine
- eGFR <60 ml/min/1.73 m2
- Retinopathy
- Neuropathy
- ABI (ankle-brachial index) <0.9

KEY POINTS:

Risk Enhancers

Family history of premature ASCVD
- Males <55 years | Females <65 years
Primary hypercholesterolemia
- LDL-C 160 to 189 mg/dL (4.1 to 4.8 mmol/L)
- Non-HDL-C 190 to 219 mg/dL (4.9 to 5.6 mmol/L)
Chronic kidney disease
- eGFR 15 to 59 ml/min per 1.73 m² with or without albuminuria
- Not treated with dialysis or kidney transplantation
Metabolic syndrome
Conditions specific to women
- Preeclampsia
- Premature menopause (before age 40)
Inflammatory disease, especially
- Psoriasis
- RA
- HIV
Ethnicity
- Asian | Hispanic/Latino | Black
- “Heterogeneity in risk according to racial/ethnic groups and within racial/ethnic groups. Native American/Alaskan populations have high rates of risk factors for ASCVD compared to non-hispanic whites.”
Lipid/biomarkers
- Persistently elevated triglycerides (≥175 mg/dL)
Additional markers if measured
- High sensitivity (hs)-CRP: ≥2.0 mg/L
- Lp(a) levels: ≥50 mg/dL or ≥125 nmol/l
- apoB: ≥130 mg/dL especially at higher levels of Lp(a)
- Elevated apo B ≥130 mg/dL corresponds to an LDL-C >160 mg/dL and constitutes a risk enhancing factor
- ABI (ankle-brachial index) <0.9

Lifestyle Discussion

Should be discussed and emphasized in each age group

Age 0 to 19
- Lifestyle discussion
- Obtain family history for Familial Hypercholesterolemia (see ‘Related ObG Topics’ below) which may require early preventative medical intervention
Age 20 to 39
- Lifestyle discussion
- Consider statin if
  - Family history | Premature ASCVD | LDL-C ≥160 mg/dL (≥4.1 mmol/L)
Age 40-75
- LDL-C ≥70 to <190 mg/dL (≥1.8 to <4.9 mmol/L) without diabetes mellitus
  - 10-year ASCVD risk percent assessment (see algorithm above)

Statin Therapy

High Intensity (≥50% LDL-C lowering)

Primary Statins
- Atorvastatin 40 to 80 mg
- Rosuvastatin 20 to 40 mg

Moderate-Intensity (30% to 49% LDL-C lowering)

Primary Statins
- Atorvastatin 10 mg to 20 mg
- Rosuvastatin 5 mg to 10 mg
- Simvastatin 40 mg
Other Statins
- Pravastatin 40 mg
- Lovastatin 40 mg
- Fluvastatin XL 80 mg
- Fluvastatin 40 mg BID
- Pitavastatin 1 to 4 mg

Low-Intensity (<30% LDL-C lowering)

Primary Statins
- Simvastatin 10 mg
Other Statins
- Pravastatin 10 to 20 mg
- Lovastatin 20 mg
- Fluvastatin 20 to 40 mg

Note: Repeat lipid measurements within 4 to 12 weeks after starting therapy and assess response as well as lifestyle changes

Statin Side Effects

Statin Associated Muscle Symptoms (SAMS)

Myalgias (1 to 5% in RCT and 5 to 10% in observational studies)
Myositis/Myopathy (rare)
- Weakness
Rhabdomyolysis (rare)
Statin-associated autoimmune myopathy (rare)

New Onset Diabetes

More common with risk factors (e.g., obesity)

Liver

Elevated transaminase (infrequent)
Hepatic failure (rare)

CNS

Impact on memory/cognition (rare/unclear)

Cancer

No definite association

Note: USPSTF differs from ACC/AHA Guidance

Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: Preventive Medication (2022)

Adults aged 40 to 75 years who have 1 or more cardiovascular risk factors (e.g., dyslipidemia, diabetes, hypertension, or smoking)
- Estimated 10-year risk of a cardiovascular event of 10% or greater (Grade B): Prescribe a statin for the primary prevention of CVD
- Estimated 10-year CVD risk of 7.5% to less than 10% (Grade C): Selectively offer a statin for the primary prevention of CVD
Adults 76 years or older
- Current evidence is insufficient to assess the balance of benefits and harms of initiating a statin for the primary prevention of CVD events and mortality (Grade I)