However, it gives a lower recommendation for low-intensity statin therapy for people with a lower 10-year risk, ie, between 7.5% and 10%. The US Preventive Services Task Force 11 recommends statins as primary preventive therapy for adults age 40 to 75 with no history of cardiovascular disease, 1 or more risk factors, and a calculated 10-year risk of 10% or greater (grade A recommendation-there is high certainty that the net benefit is moderate, or there is moderate certainty that the net benefit is moderate to substantial). The addition of the “borderline” group (only the 2018 guidelines specifically mention and explain primary preventive treatment in the “borderline” risk category) reflects the uncertainty of treatment strategies for patients at intermediate risk, while treatment recommendations for high- and low-risk groups are well established. This tool gives an estimate of the patient’s risk of a cardiovascular event within the next 10 years, which the guidelines categorize as follows: Use the Pooled Cohort Equations, which are based on age, sex, race, total cholesterol, high-density lipoprotein cholesterol, systolic blood pressure, and whether the patient is receiving treatment for high blood pressure, has diabetes, or smokes (class I recommendation). In this group, the guidelines say to use a risk calculator to determine if the patient needs lipid-lowering medication. 4, 6, 7Īdults age 40–75, without diabetes, with LDL-C levels 70–189 mg/dL Several trials showed that PCSK9 inhibitors reduce cardiovascular risk in patients with stable atherosclerotic cardiovascular disease or recent acute coronary syndromes who are already on moderate- or high-intensity statin therapy. PCSK9 inhibitors lower LDL-C by 50% to 60% by binding to PCSK9, inhibiting labeling of LDL receptors for degradation, thus prolonging LDL receptor activity at the cell membrane. A large randomized trial in patients who recently had acute coronary syndromes showed that ezetimibe modestly reduced cardiovascular risk over 7 years of follow-up when added to their regimen of moderate-intensity statin therapy. 4– 7Įzetimibe decreases cholesterol absorption and consequently lowers LDL-C levels by about 20%. The nonstatin LDL-lowering drugs such as ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors can be added to statin therapy, as recent randomized clinical trials found them to improve cardiovascular outcomes in patients with atherosclerotic cardiovascular disease. Here, we review the recent guidelines and discuss the most important changes for clinical practice. The guidelines also discuss the cost and value of each treatment option for each treatment group. In secondary prevention, the guidelines group patients according to their risk (high risk vs very high risk) and incorporate new nonstatin therapies as add-on, evidence-based treatment options when low-density lipoprotein (LDL-C) remains above the 70 mg/dL threshold. In primary prevention, the guidelines provide clarity regarding decision-making in patients at intermediate risk of atherosclerotic cardiovascular disease (“intermediate” meaning a 7.5%–20% 10-year risk). The new guidelines have updated patient risk assessment and treatment options in primary and secondary prevention. The American College of Cardiology (ACC) and American Heart Association (AHA) Task Force on Clinical Practice Guidelines published its most recent guidelines for cholesterol management in 2018, 1 and followed it with guidelines for primary prevention of cardiovascular disease in 2019. Special treatment algorithms are outlined for certain patient subgroups, such as certain ethnic groups, adults with chronic kidney disease, those with human immunodeficiency virus infection, and women. Statins are the foundation of pharmacologic therapy, to which ezetimibe and, if necessary, a proprotein convertase subtilisin/kexin type 9 inhibitor can be added to achieve lipid goals. Emphasize a heart-healthy lifestyle for all patients across their life span.Ī discussion with the patient is the cornerstone of shared decision-making and should include the patient’s 10-year risk of atherosclerotic cardiovascular disease according to the Pooled Cohort Equations, as well as risk-enhancing factors.
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