Overview of new ACC/AHA lipid guidelines: here we go again

Reference

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. J Am Coll Cardiol 2018;S0735-1097(18)39034-X. [Epub ahead of print]

Synopsis

This is an update to the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines, which were the first to base treatment decisions primarily on the 10-year risk of an atherosclerotic vascular disease (ASCVD) event rather than on specific LDL targets. This guideline engenders a bit of "Here we go again…" with a re-emphasis on regularly measuring lipids and a return to an LDL target for assessing effectiveness and deciding when to prescribe one of the new and pricey PSK9 inhibitors (US$14,000 to $15,000 per year at www.goodrx.com, 12/1/18). Statins are divided into high intensity (atorvastatin 40 to 80 mg, rosuvastatin 20 to 40 mg), moderate-intensity statin (atorvastatin 10 to 20 mg, simvastatin 20 to 40 mg, rosuvastatin 5 to 10 mg), and low intensity (simvastatin 10 mg) groups. For primary prevention in persons 20 to 39 years, the guidelines recommend an assessment of the lifetime risk of ASCVD as a way to frighten patients into compliance with lifestyle changes. For 20 to 39 year olds with LDL greater than 160 or a family history of premature ASCVD, a statin is recommended. For patients older than 40 years, a high-intensity statin is recommended for an LDL greater than 190 mg/dL and a moderate- or high-intensity statin (depending on other risk factors) for those with diabetes. For all other patients, the Pooled Cohort Equations are used to place patients into 1 of 4 risk groups; the old guideline had only 3. (Feel free to skip the next section and refer to the guideline itself, which provides a descriptive figure.) If the 10-year risk of an ASCVD event is less than 5%, no statin is recommended. If the 10-year risk is 5% to 7.5%, consider a moderate-intensity statin if there is also a "risk enhancer," such as LDL greater than 160 mg/dL, family history of premature ASCVD, chronic kidney disease, metabolic syndrome, South Asian ancestry, preeclampsia, HIV, rheumatoid arthritis, or psoriasis. Thanks, guys, another long list to memorize! For persons with a 7.5% to 20% risk, they recommend a moderate-intensity statin for most patients to target a 30% to 49% reduction in LDL. Finally, if risk is greater than 20%, a statin to target a 50% or more reduction in LDL cholesterol is recommended. For prevention in persons with known vascular disease, a new category of "very high risk" is described. It is defined as 2 or more of the following major events: acute coronary syndrome in the past 12 months, previous myocardial infarction, previous ischemic stroke, or symptomatic peripheral artery disease. A patient is also very high risk if they have one of those major ASCVD events and multiple high-risk conditions, such as familial hypercholesterolemia, age at least 65 years, hypertension, diabetes, chronic kidney disease, tobacco use, heart failure, or LDL greater than 100 despite maximal statin plus ezetimibe. Patients in this category should be taking a high-intensity statin, adding ezetimibe if necessary, to target an LDL of 70 mg/dL. If that is not achieved, and only then, should a PSK9 inhibitor be considered. Regarding PSK9 inhibitors, it is notable that the guideline cautions that "the long-term safety (>3 years) is uncertain and cost effectiveness is low at mid-2018 list prices." Although the previous guideline was silent on the question of monitoring lipid levels, this one recommends regular monitoring (at least once per year) to verify adherence to the medication and to estimate the percentage reduction in LDL level. Finally, it's also worth noting which organizations were not among the 12 that endorsed this guideline: the American Academy of Family Physicians (AAFP) and the American College of Physicians (ACP). This is reminiscent of the recent, aggressive hypertension guidelines from the ACC/AHA that the AAFP and ACP also did not participate in or endorse.