OPTIMIZING LIPID MANAGEMENT

Clinical Practice Recommendations on the Management of Dyslipidemia Recognize That Lower LDL-C Is Better in Patients With ASCVD1,2

Current guidelines recommend intensifying lipid-lowering in patients with very-high risk atherosclerotic cardiovascular disease (ASCVD) based on specific low-density lipoprotein cholesterol (LDL-C) goals and thresholds.2,* Recognizing the effect of LDL-C reductions in lowering cardiovascular (CV) risk in patients with very high-risk established cardiovascular disease (CVD), cholesterol guideline recommendations have evolved over time to recommend more intensive LDL-C lowering.1-3

With Each Update, LDL-C Recommendations Have Lowered1,4-17

*In very high-risk ASCVD (see “Very High-Risk Patients Are Clearly Defined With Specific LDL-C Recommendations in Current Cholesterol Guidelines”, side 1), use an LDL-C threshold of 70 mg/dL to consider the addition of non-statins to statin therapy. A threshold is the point/trigger at which intensification of therapy may be considered. Additional AHA/ACC guidelines were published in 2013 but did not provide a recommendation for target LDL-C levels to reduce the ASCVD risk.18 †Progressive ASCVD, including unstable angina that persists after achieving an LDL-C < 70 mg/dL, or established clinical ASCVD in individuals with diabetes, CKD stage 3 or 4, and/or HeFH, or in individuals with a history of premature ASCVD (< 55 years of age for males or < 65 years of age for females).

AACE, American Association of Clinical Endocrinologists; ACC, American College of Cardiology; ACE, American College of Endocrinology; AHA, American Heart Association; ASCVD, atherosclerotic cardiovascular disease; ATP, Adult Treatment Panel; CKD, chronic kidney disease; CV, cardiovascular; EAS, European Atherosclerosis Society; ESC, European Society of Cardiology; HeFH, heterozygous familial hypercholesterolemia; LDL-C, low-density lipoprotein cholesterol; NCEP, National Cholesterol Education Program; NLA, National Lipid Association.

Clinical Guidelines Define Patients With ASCVD Who Are at Increased Risk of CV Events and Advise Intensive LDL-C Lowering With Non-Statin Therapies1,2,7,8,17

Click here to learn about a non-statin treatment option.

*Patients fall into the respective designation if they have one or more of the listed criteria. †PCI, CABG, and other arterial revascularization procedures. **Very high-risk patients have a history of multiple major ASCVD events or 1 major ASCVD event and multiple high-risk conditions, as previously defined in the 2018 AHA/ACC/Multi-Society cholesterol guideline. ††Consider initiating non-statin therapies after evaluating and optimizing: lifestyle, adherence to guideline-recommended statin therapy, risk factor control and statin-associated side effects, and escalating to high-intensity statins if not already taking.

AACE, American Association of Clinical Endocrinology; ACC, American College of Cardiology; ACS, acute coronary syndrome; AHA, American Heart Association; ASCVD, atherosclerotic cardiovascular disease; CABG, coronary artery bypass grafting; CKD, chronic kidney disease; CV, cardiovascular; DM, diabetes mellitus; EAS, European Atherosclerosis Society; ESC, European Society of Cardiology; FH, familial hypercholesterolemia; heFH, heterozygous familial hypercholesterolemia; HF, heart failure; HTN, hypertension; IS, ischemic stroke; LDL-C, low-density lipoprotein – cholesterol; PAD, peripheral artery disease; PCI, percutaneous coronary intervention; TIA, transient ischemia attack; UA, unstable angina.

Additional Resources

Learn more about current clinical practice recommendations in our Resource Library.

Learn More

Most Patients With Established ACS Meet the Definition of Very High-Risk

Over 90% of Patients With Recent ACS Met the 2018 AHA/ACC Guideline Criteria for ASCVD19

Retrospective cohort study analyzed data from US adults with health insurance in the MarketScan database who had experienced an ACS in the past year (recent ACS, n = 3,626), a myocardial infarction other than a recent ACS (n = 7572), an ischemic stroke (n = 3551), or symptomatic peripheral artery disease (n = 5,919). Patients were followed from January 1, 2016 to December 31, 2017 for recurrent ASCVD events.

ACC, American College of Cardiology; ACS, acute coronary syndrome; AHA, American Heart Association; ASCVD, atherosclerotic cardiovascular disease; CABG, coronary artery bypass graft; PCI, percutaneous coronary intervention; VHR, very high-risk

Overall Rates of Major CV Events Are Notably Higher in Patients With VHR ASCVD Than in Patients With Non-VHR ASCVD20

Retrospective cohort study analyzed data from US adults included in the Prognos LDL-C database from January 1, 2011 to June 30, 2018. Patients were ≥ 18 years old and had ≥ 2 non-ancillary medical claims in the linked databases at least 30 days apart. The study was conducted in two stages: 1) identification of patients with ASCVD who met the definition of VHR ASCVD and a matched cohort of non-VHR ASCVD patients using the incidence density sampling approach; 2) estimation of the occurrence of major CV events.

ASCVD, atherosclerotic cardiovascular disease; CV, cardiovascular; IS, ischemic stroke; LDL-C, low-density lipoprotein cholesterol; MI, myocardial infarction; revasc, revascularization; UA, unstable angina; VHR, very high-risk.

  1. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol. Circulation. 2019;139(25):e1046-e1081. doi:10.1161/CIR.0000000000000624.
  2. Mach F, Baigent C, Catapano AL, et al. 2019 ESC/EAS guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J. 2020;41(1):111-188. doi:10.1093/eurheartj/ehz455.
  3. Masana L, Girona J, Ibarretxe D, et al. Clinical and pathophysiological evidence supporting the safety of extremely low LDL levels – the zeroLDL hypothesis. J Clin Lipidol. 2018;12(2):292-299.e3. doi:10.1016/j.jacl.2017.12.018.
  4. Goodman DS, Hulley SB, Clark LC, et al. Report of the National Cholesterol Education Program expert panel on detection, evaluation, and treatment of high blood cholesterol in adults. Arch Intern Med. 1988;148(1):36-69. doi:10.1001/archinte.1988.00380010040006.
  5. Grundy SM, Bilheimer D, Chait A, et al. Summary of the second report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel II). JAMA. 1993;269(23):3015-3023. doi:10.1001/ jama.1993.03500230097036.
  6. NCEP. Third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III) final report. Circulation. 2002;106(25):3143-3421.
  7. Jellinger PS, Handelsman Y, Rosenbilt PD, et al. American Association of Clinical Endocrinologists and American College of Endocrinology guidelines for management of dyslipidemia and prevention of cardiovascular disease. Endocr Pract. 2017;23(suppl2):1-87. doi:10.4158/ ep171764.appgl.
  8. Handelsman Y, Jellinger PS, Guerin CK, et al. Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the management of dyslipidemia and prevention of cardiovascular disease algorithm – 2020 executive summary. Endocr Pract. 2020;26:1196-1224. doi:10.4158/CS-2020-0490.
  9. Reiner Z, Catapano AL, De Backer G, et al. ESC/EAS guidelines for the management of dyslipidemias: the Task Force for the management of dyslipidemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS). Eur Heart J. 2011;32:1769-1818. doi:10.1093/eurheartj/ehr158
  10. Catapano AL, Graham I, De Backer G, et al. 2016 ESC/EAS guidelines for the management of dyslipidemias. Eur Heart J. 2016;37(39):2999-3058.
  11. Mach F, Baigent C, Catapano AL, et al. 2019 ESC/EAS guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J. 2020;41(1):111-188. doi:10.1093/eurheartj/ehz455.
  12. Wood D, De Backer G, Faergeman O, et al. Prevention of coronary heart disease in clinical practice: summary of recommendations of the Second Joint Task Force of European and other societies on coronary prevention. Eur J Gen Pract. 1999;5:154-161. doi:10.3109/13814789909094289
  13. De Backer G, Ambrosioni E, Borch-Johnsen K, et al. European guidelines on cardiovascular disease prevention in clinical practice. Third Joint Task Force of European and other societies on cardiovascular disease prevention in clinical practice (Constituted by representatives of eight societies and by invited experts). Atherosclerosis. 2004;173:381-391
  14. Graham I, Atar D, Borch-Johnsen K, et al. European guidelines on cardiovascular disease prevention in clinical practice: executive summary: Fourth Joint Task Force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of nine societies and by invited experts). Eur Heart J. 2007;28:2375-2414. doi:10.1093/eurheartj/ehm316
  15. Jellinger PS, Smith DA, Mehta AE, et al. American Association of Clinical Endocrinologists' guidelines for management of dyslipidemia and prevention of atherosclerosis. Endocr Pract. 2012;18(suppl1):1-78.
  16. Jacobson TA, Ito MK, Maki KC, et al. National Lipid Association recommendations for patient-centered management of dyslipidemia: Part 1 – executive summary. J Clin Lipidol. 2014;8(5): 473-488. doi:10.1016/j.jacl.2014.07.007.
  17. Lloyd-Jones DM, Morris PB, Ballantyne CM, et al. 2022 ACC expert consensus decision pathway on the role of nonstatin therapies for LDL-cholesterol lowering in the management of atherosclerotic cardiovascular disease risk: a report of the American College of Cardiology solution set oversight committee. J Am Coll Cardiol. 2022;80(14):1366–1418.
  18. Stone NJ, Robinson JG, Liechtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. 2014;63(25 Pt B):2889-2934. doi:10.1016/j.jacc.2013.11.002.
  19. Muntner P, Orroth KK, Mues KE, et al. Evaluating a simple approach to identify adults meeting the 2018 AHA/ACC cholesterol guideline definition of very high risk for atherosclerotic cardiovascular disease. Cardiovasc Drugs Ther. 2022;36(3):475-481. doi:10.1007/s10557-021-07167-1.
  20. Fonarow GC, Kosiborod MN, Rane PB, et al. Patient characteristics and acute cardiovascular event rates among patients with very high-risk and non-very high-risk atherosclerotic cardiovascular disease. Clin Cardiol. 2021;44(10):1457-1466. doi:10.1002/clc.23706.

Lipid Management in Patients With Recent MI

Webinar: Guidelines, Discharge Protocol, and Routine Follow-up to Optimize Treatment in Patients
With Recent MI

Watch a sponsored webinar on guidelines, discharge protocol, and routine follow-up in patients with recent myocardial infarction (MI).

According to the 2022 ACC Expert Consensus Decision
Pathway (ECDP), which threshold is recommended for
intensifying LDL-C therapy in patients
with very high risk ASCVD? (1 of 3)
I am comfortable implementing the
recommendations outlined in the 2022 ACC Expert Consensus
Decision Pathway. (2 of 3)
I am successful in identifying patients who need
intensification of lipid lowering therapy. (3 of 3)
Your answers have been submitted.
Thank you!