2018 Cholesterol Guidelines: Secondary ASCVD Prevention

Although current guidelines are an honest attempt in reflecting complex medical evidence from clinical trials, they may not be very practical or user-friendly to general practitioners.

A simplified but reasonable approach to lipid management for secondary ASCVD prevention would be:

  • Patients with established clinical ASCVD should achieve LDL-cholesterol <70 mg/dL by using statins ± ezetimibe ± PCSK9 inhibitors.

GT

Also see:

Lipids Guidelines

Dyslipidemia

Atherosclerosis


Circulation

Lipid Guidelines

November 2018

Secondary ASCVD Prevention 

Younger ≤75 + NOT very-high risk 

  • In patients ≤75 with clinical ASCVD, high-intensity statin therapy should be initiated or continued with the aim of achieving ≥50% reduction in LDLc levels 

  • In patients with clinical ASCVD in whom high-intensity statin therapy is contraindicated or who experience statin-associated side effects, at least moderate-intensity statin therapy should be initiated or continued with the aim of achieving a 30-49% reduction in LDLc levels 

 

Younger ≤75 + VERY-high risk 

  • In patients with clinical ASCVD who are on maximally tolerated statin therapy + at very high risk and have an LDLc level of ≥70 mg/dL, it is reasonable to add ezetimibe therapy 

  • In patients with clinical ASCVD + at very high risk and considered for PCSK9 inhibitor therapy, maximally tolerated LDLc lowering therapy should include maximally tolerated statin ezetimibe therapy. 

  • In patients with clinical ASCVD + at very high risk and who are on maximally tolerated oral LDL-C lowering therapy with ≥LDLc 70 or a nonHDLc level of ≥100, it is reasonable to add a PCSK9 inhibitor following a clinician–patient discussion about the net benefit, safety, and cost. 

 

Older >75 

  • In patients >75 with clinical ASCVD, it is reasonable to initiate moderate-high intensity statin therapy after evaluation of the potential for ASCVD risk reduction, adverse effects, and drug–drug interactions, as well as patient frailty and patient preferences  

  • In patients >75 who are tolerating high-intensity statin therapy, it is reasonable to continue high-intensity statin therapy after evaluation of the potential for ASCVD risk reduction, adverse effects, and drug-drug interactions, as well as patient frailty and patient preferences. 

Other: 

  • In patients with clinical ASCVD who are receiving maximally tolerated statin therapy and whose LDL-C level remains ≥70 mg/dL, it may be reasonable to add ezetimibe 

  • In patients with heart failure (HF) with reduced EF attributable to ischemic heart disease who have a reasonable life expectancy (3-5 years) and are not already on a statin because of ASCVD, clinicians may consider initiation of moderate-intensity statin therapy to reduce the occurrence of ASCVD events.


Clinical ASCVD definition:

  • Acute coronary syndrome (ACS) 

  • Myocardial infarction (MI) 

  • Stable or unstable angina 

  • Coronary revascularization 

  • Other arterial revascularizations  

  • Stroke 

  • Transient ischemic attack (TIA) 

  • Peripheral artery disease (PAD)  

  • PAD from an aortic aneurysm 

  • PAD of any atherosclerotic origin


VERY HIGH RISK of future ASCVD events:

  • Multiple major ASCVD events, or 

  • One major ASCVD event + multiple high-risk conditions. 


Major ASCVD events and HIGH-RISK conditions

  • Symptomatic PAD

    • History of claudication with ABI <0.85 

    • Previous revascularization 

    • Previous amputations 

  • ACS within the past 12 months 

  • History of MI  

  • History of ischemic STROKE 

  • History of CABG or PCI

  • History of CHF 

  • Diabetes Mellitus

  • CKD with eGFR 15-59

  • Hypertension

  • Current smoking 

  • Age ≥65

  • LDLc ≥190 

  • LDLc ≥100 + maximally tolerated statin + ezetimibe

 
Broken Heart