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:

  • 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
Broken Heart
 
  • 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
Broken Heart
 
  • 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

Secondary Prevention

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
Broken Heart