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:
- 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 LDLc 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, 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
- 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 LDLc 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, 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
- Patients with established clinical ASCVD should achieve LDL-cholesterol <70 mg/dL by using statins ± ezetimibe ± PCSK9 inhibitors.
GT
Also see:
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 LDLc 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, 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