By Alison L. Bailey, MD, FAACVPR, FACC | December 5, 2018

The 2013 ACC/AHA Cholesterol Guidelines were updated and recently presented at the American Heart Association 2018 meeting in Chicago.¹ The recent guidelines represent a consensus statement from the AHA, ACC, AACVPR, AAPA, ABC, ACPM, ADA, AGS, APhA, ASPC, NLA, and the PCNA.

These guidelines focus on a healthy lifestyle as the background for all patients and then look at the groups with a documented benefit (atherosclerotic cardiovascular disease—ASCVD; diabetics; familial hypercholesterolemia; and primary prevention with 10 year risk estimated by the pooled cohorts equation (PCE) ≥ 5 percent with risk enhancers or ≥ 7.5 percent.

For those who fall into the primary prevention category, there is an ASCVD PCE risk calculator app and website that can be accessed by all rehab staff.² This should be a part of risk evaluation in all patients who do not have an ASCVD indication when entering cardiac rehab.

As the patients attending cardiac rehab are mostly secondary prevention, we will focus on these individuals with the guideline update. For those patients with ASCVD, cardiac rehab programs should work with the medical director and the referring cardiologist to optimize lipid therapies.

The guidelines emphasize the following points:

1. In all individuals, emphasize a heart-healthy lifestyle across the life course.

• A healthy lifestyle reduces atherosclerotic cardiovascular disease (ASCVD) risk at all ages.
• In younger individuals, healthy lifestyle can reduce development of risk factors and is the foundation of ASCVD risk reduction and the primary intervention for metabolic syndrome.

2. In patients with clinical ASCVD, reduce low-density lipoprotein cholesterol (LDL-C) with high-intensity statin therapy or maximally tolerated statin therapy.

• The more LDL-C is reduced on statin therapy, the greater will be subsequent risk reduction.
• Use a maximally tolerated statin to lower LDL-C levels by ≥ 50 percent.

3. In very high-risk ASCVD, use a LDL-C threshold of 70 mg/dL to consider addition of nonstatins to statin therapy.

• Very high-risk includes a history of multiple major ASCVD events or 1 major ASCVD event and multiple high-risk conditions.
• In very high-risk ASCVD patients, it is reasonable to add ezetimibe to maximally tolerated statin therapy when the LDL-C level remains ≥70 mg/dL.
• In patients at very high risk whose LDL-C level remains ≥70 mg/dL on maximally tolerated statin and ezetimibe therapy, adding a PCSK9 inhibitor is reasonable, although the long-term safety (>3 years) is uncertain and cost effectiveness is low at mid-2018 list prices.

4. In patients with severe primary hypercholesterolemia (LDL-C level ≥190 mg/dL) or aged 40 to 75 years of age with diabetes mellitus and LDL-C ≥70 mg/dL, statin therapy should be instituted without calculating 10-year ASCVD risk.

5. In adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dL at a 10-year ASCVD risk of ≥ 7.5 percent, start a moderate-intensity statin if a discussion of treatment options favors statin therapy.

• Risk discussion should include a review of major risk factors (e.g., cigarette smoking, elevated blood pressure, LDL-C, hemoglobin A1C and calculated 10-year risk of ASCVD); the presence of risk-enhancing factors; the potential benefits of lifestyle and statin therapies; the potential for adverse effects and drug–drug interactions; consideration of costs of statin therapy; and patient preferences and values in shared decision-making
• If risk status is uncertain, consider using coronary artery calcium (CAC) to improve specificity. 
• Risk-enhancing factors favor statin therapy and include:
  • Family history of premature ASCVD;
  • Persistently elevated LDL-C levels ≥160 mg/dL;
  • Metabolic syndrome;
  • Chronic kidney disease;
  • History of preeclampsia or premature menopause (age <40 years);
  • Chronic inflammatory disorders (e.g., rheumatoid arthritis, psoriasis, or chronic HIV);
  • High-risk ethnic groups (e.g., South Asian);
  • Persistent elevations of triglycerides ≥175 mg/dL; and, if measured in selected individuals, apolipoprotein B ≥130 mg/dL, high-sensitivity C-reactive protein ≥2.0 mg/L, ankle-brachial index <0.9 and lipoprotein (a) ≥50 mg/dL or 125 nmol/L, especially at higher values of lipoprotein (a).

6. In adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dL- 189 mg/dL, at a 10-year ASCVD risk of ≥ 7.5 percent to 19.9 percent, if a decision about statin therapy is uncertain, consider measuring CAC.

• If CAC is zero, treatment with statin therapy may be withheld or delayed — except in cigarette smokers, those with diabetes mellitus and those with a strong family history of premature ASCVD.
• For any patient, if the CAC score is ≥100 Agatston units or ≥75th percentile, statin therapy is indicated unless otherwise deferred by the outcome of clinician–patient risk discussion.

7. Assess adherence and percentage response to LDL-C–lowering medications and lifestyle changes with repeat lipid measurement four to 12 weeks after statin initiation or dose adjustment, repeated every three to 12 months as needed.

These guidelines represent a change from the current practice. There are now “goals” again for LDL cholesterol, which will be an area where cardiac rehab programs can influence change.

I would recommend considering the following when patients are entering cardiac rehab:

• ASCVD:
  • The goal for the majority of our patients will be to take a high-intensity statin (atorvastatin 40 mg – 80 mg; rosuvastatin 20 mg – 40 mg ) to reduce LDL levels to < 50 percent of the starting value AND maintain an LDL-C < 70 mg/dL if considered very high-risk ASCVD.
  • Very high-risk includes a history of multiple major ASCVD events or 1 major ASCVD event and multiple high-risk conditions.
  • If LDL-C remains ≥70 mg/dL on maximally tolerated statin therapy, then ezetimibe should be considered.
  • If LDL-C remains ≥70 mg/dL on maximally tolerated statin therapy plus ezetimibe, adding a PCSK9 inhibitor is reasonable, although the long-term safety (>3 years) is uncertain and cost effectiveness is low at mid-2018 list prices.

References

1. Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, Braun LT, de Ferranti S, Faiella-Tommasino J, Forman DE, Goldberg R, Heidenreich PA, Hlatky MA, Jones DW, Lloyd-Jones D, Lopez-Pajares N, Ndumele CE, Orringer CE, Peralta CA, Saseen JJ, Smith SC Jr, Sperling L, Virani SS, Yeboah J. 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.
2. http://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/