Heart healthy lifestyle habits are the most important foundation of disease prevention.However, despite many of our patients’ best efforts, their elevated cholesterol levels will put them at a high risk for cardiovascular disease. Additionally, many of our patients already suffer from atherosclerotic vascular disease (AVSCD) including stroke, peripheral arterial disease (PAD), and coronary heart disease (CHD). Multiple randomized controlled trials (RCTs) have demonstrated that statins can prevent cardiovascular events and decrease mortality.
Changes in the 2013 update
The American Heart Association (AHA) and American College of Cardiology (ACC) utilized recommendations from an Institute of Medicine (IOM) Committee’s recommendations on guideline development. Therefore, only RCTs, strong meta-analyses, and systemic reviews were utilized in guideline development. Since RCTs have not used the "treat-to-target" approach and have focused on a fixed dose of a statin, the newest cholesterol recommendations no longer recommend treating to cholesterol "goals."
|Adult Patient Population (>21 years old)||Recommendation|
|Individuals with clinical ASCVD (established coronary heart disease, stroke or peripheral arterial disease)||If ≤75 years old, add a high intensity statin If > 75 years old, or cannot tolerate a high-intensity statin add a moderate intensity statin|
|Individuals with LDL–C values ≥190 mg/dL||Add a high intensity statin|
|Individuals 40 to 75 years of age with diabetes with LDL-C 70-189 mg/dL||Add a moderate intensity statin unless estimated 10-year ASCVD risk ≥7.5%. Then add a high intensity statin.|
|Individuals without clinical ASCVD or diabetes who are 40 to 75 years of age with LDL 70-189 mg/dL and an estimated 10-year ASCVD risk of 7.5% or higher||Add a moderate to high intensity statin|
|High-Intensity Statins (Lower LDL by ≥50%)||Moderate-Intensity Statins (Lower LDL by 30-50%)|
|Atorvastatin 80mg ¥*||Atorvastatin 10-20mg*|
|Rosuvastatin (Crestor) 20 or 40mg||Rosuvastatin (Crestor) 5-10mg|
¥ May down-titrate to 40mg if unable to tolerate 80mg
New Method of Calculating AVSCD Risk
The guidelines no longer utilize the Framingham Coronary Risk score to determine risk and guide therapy. The new assessment estimates 10-year risk for an ASCVD event that includes both CHD and stroke, whereas the Framingham Calculator only estimated risk of nonfatal MI and CHD death. The 10-year ASCVD risk calculator tools can be found here: http://my.americanheart.org/cvriskcalculator
Monitoring Remains the Same
Evidence supports the use of an initial fasting lipid panel. Four to 12 weeks after initiation of statin therapy, a second fasting lipid panel is indicated to assess adherence. Thereafter, assessments should be performed every 3 to 12 months as clinically indicated.
The short answer: a lot. The new guidelines don’t address hypertriglyceridemia (unless TG >500mg/dL), use of non-HDL in decision-making, optimal age to initiate statins, statin benefit in heart failure and hemodialysis, etc.
These are decision-making guidelines, not intended to cover every patient scenario. They are a representation of the current best available evidence for the treatment and prevention of AVSCD.
By Emily Kosirog & Jeff Freund, PharmD