High Cholesterol Diet and Exercise First in Ser

More personalized risk assessment and the possibility of using new cholesterol-lowering treatment options for people with a higher risk of CVD, as well as using non-invasive coronary artery screening (CAC) for decision-making in patients who are in the gray area of ​​treatment. These are the main recommendations contained in the new guidelines for cholesterol (LG) 2018, developed by the American Heart Association (AHA) and American College of Cardiology (ACC).

More personalized risk assessment and the possibility of using new cholesterol-lowering treatment options for people with a higher risk of CVD, as well as using non-invasive coronary artery screening (CAC) for decision-making in patients who are in the gray area of ​​treatment. These are the main recommendations contained in the new guidelines for cholesterol (LG) 2018, developed by the American Heart Association (AHA) and American College of Cardiology (ACC).

LG was presented in Chicago where the AHA Congress was held every year, and was published in AHA "Circulation" and "Journal of the American College of Cardiology".

The ACC / AHA – 121 pages, which required 18 months in preparation – contains 72 recommendations, of which 29 in 1st grade and confirmed by many other scientific companies: American Association of Cardiovascular Pulmonary Rehabilitation, American Academy of Medical Assistants, Association of Black Cardiologists, American High Preventive Medicine School, American Diabetic Association, American Geriatrics, American Pharmacy Association, American Society for Preventive Cardiology, the National Lipid Association, and the Preventive Association of Cardiovascular Nurses.

1-Presentation and general overview of the document

(a) a substantive statement
"The updated guidelines reinforce the importance of healthy living, lifestyle changes and prevention, based on the major change we made in the cholesterol recommendations in 2013 to focus on identifying and managing life risks for CVD," he said Ivor Benjamin, president of the American Heart Association.

"High cholesterol at any age significantly increases this risk, so it's so important that even at a young age people keep a healthy lifestyle of their hearts and maintain the right cholesterol level to stay healthy."

The guidelines for 2018 highlight that high cholesterol "at any age" significantly increases the risk of occupational death, and recommends timely risk assessment, including in children and young adults. "While there is no target for ideal LDL cholesterol levels in the general population, the guideline generally recognizes that less is better" (lower is better), "Benjamin added.

Nearly one out of three adult adult Americans have high levels of low-density lipoprotein cholesterol (LDL-C), which contributes to lipid plaque accumulation and arterial narrowing, in Chicago. About 94.6 million (39.7%) of adult Americans have a total cholesterol of 200 mg / dL or higher, while research shows that people with LDL-C levels of 100 mg / dL or less tend to have lower rates of heart disease and stroke, confirming the correctness of philosophy that "less is better".

"Treatment of hypercholesterolemia is not universal for everyone, and this LG strongly demonstrates the importance of personal care," he added. Michael Valentine, chairman ACC. "Over the last five years, we have learned even more about new treatment options and what patients can benefit from. By providing doctors with a treatment plan, we provide them with tools that help patients understand and manage their risk and live healthier and longer time. "

Richard Kovacs, Indiana University School of Medicine in Indianapolis, Vice President ACC, said the latest guidelines will help transform CV help and improve heart health. "Hypercholesterolemia is often preventative and basically curative, but when we enter an era where personal care is individual, the way we treat individual patients may vary," Kovacs said. "This instruction will give doctors the tools we need to work with the patient to find the most appropriate treatment for their high cholesterol."

b) Cardiovascular risk calculator and treatment personalization
A special report, published at the same time as an annex to the LG Cholesterol Directive, provides a more detailed view of the use of quantitative risk assessments in the prevention of primary CVD. The ASCVD Risk Calculator, introduced in the 2013 guidelines, remains the basic tool to help health professionals identify the risk of CVD for ten years.

Because the calculator uses population-based formulas, LG is now calling on physicians to talk to the patient about "risk factors" that, in addition to traditional risk factors such as smoking, can provide a more personalized view of the person's risk. , high blood pressure and high blood sugar to solve the undersigned or overweight in some individuals.

Risk factors include family history and ethnicity, as well as certain medical conditions such as metabolic syndrome, chronic kidney disease, chronic inflammatory conditions, premature menopause, or preeclampsia, and high-lipid biomarkers. This additional information may indicate a difference in the type of treatment plan the person needs.

In primary and secondary prevention, where high cholesterol can not be controlled by diet or exercise, the first treatment line is typically made up of statins that are mostly available in generic and long-term forms to safely reduce effective LDL-C and CVD risk.

For people who have had a heart attack or stroke and are at a higher risk of relapse and whose LDL-C levels are not sufficiently reduced in statin therapy, the recommendation now recommends selecting other medicines to add cholesterol to ongoing treatment.

Before discussing in detail the detailed aspects of the document, we summarize the key concepts expressed in the document update.

Key points of the new AHA / ACC guidelines for managing hypercholesterolaemia

  • High cholesterol at any age can increase the risk of heart disease and stroke in a person's life. Healthy lifestyle is the first step in prevention and treatment to reduce this risk.
  • The AHA 2018 guidelines recommend more detailed risk assessments to help healthcare professionals better identify individualized risks and treatment options.
  • In some cases calcium calcium calcium quantification can determine whether a person needs cholesterol lowering if his or her risk status is uncertain or if treatment decisions are unclear.
  • Although statins are still the first choice among cholesterol lowering drugs, new treatment options are available for people who have had a heart attack or stroke and are at higher risk for another. For these people, drugs should be prescribed by a scalar approach, first by statin treatment at maximum intensity, by addition of ezetimibe, if the desired LDL cholesterol levels are not achieved, and then by the addition of PCSK9 inhibitor, another reduction in cholesterol.

When should statins be used?
The new document has many common aspects with guidelines for 2013, in particular the definition of the four main categories of patients with different management needs for which statins can be considered:

  • primary prevention: ie no clinic of atherosclerotic cardiovascular disease (ASCVD) or diabetes, but LDL-C levels of 70 mg / dL or higher and a risk of 10 years according to the calculator of 7.5% or more;
  • absence of clinical ASCVD, but the presence of diabetes and an LDL-C level of 70 mg / dL or higher;
  • secondary prevention: ie the ASCVD clinic without heart failure;
  • severe primary hypercholesterolemia (LDL-C => 190 mg / dL), often called FH.

When to use anti PCSK9?
LG recommends PCSK9 inhibitors (whose primary randomized trials were introduced after 2013), particularly in patients with familial hypercholesterolaemia (FH) and in patients with a very high risk of LDL-C high ASCVD despite statin-tolerated dose and ezetimibe supplementation.

In the second group, initiation of neutropenase-lowering lipid therapy should be considered in all patients with LDL-C levels that did not fall below 70 mg / dL.

2- Recommendation in more detail and specifically

This new document – edited by the editorial board Scott M. Grundy, University of Texas Southwestern Medical Center in Dallas, and co-chaired Neil J. Stone, Northwestern University of Chicago – Maintains key ideas and innovative principles introduced in the previous version of 2013. Additionally, the new LG AHA / ACC 2018 for cholesterol management provides specific guidelines for the use of anti-PCSK9, ie Evolokumab and alirobumab,

In particular, LG 2018 keeps one of the most controversial innovations in 2013, a 10-year ASCVD risk assessment system, but has been modified to include more population data than before. In particular, it seems to reduce the impact of the ASCVD risk calculator as a statin trigger.

To a large extent, the maximum effect is limited to the renewal of LDL-C treatment targets, especially for risk groups, and extensive patient-to-doctoral communications for joint decision making, particularly for primary prevention patients with transient risk.

In the second group, coronary artery calcium (CAC) score scores are retained for limited use as a potential contribution to decision making on statin use.

a) Primary prevention
From the 2013 document, "we have renewed access to risk assessment in primary prevention, but it still starts with a calculated risk estimate of 10 years," wrote a committee member Donald Lloyd-Jones, Northwestern University of Feinberg School of Medicine in Chicago. "This must be the starting point," Lloyd-Jones said, as the risk score affects the intensity of the management program, both by modifying lifestyle and drug therapy.

"While the risk calculator has not been re-calibrated, there is now much wider guidance on how the patient and clinician should approach a risk discussion that did not receive such attention in 2013," he said Roger S. Blumenthal, Director of the Johns Hopkins Ciccarone Heart Disease Prevention Center.

Like the 2013 recommendation, the ACC / AHA 2018 Cholesterol Guidelines highlight a discussion of the benefits and disadvantages of initiating statin treatment for primary prevention of ASCVD. This discussion should include an overview of major risk factors – including cigarette smoking, blood pressure, LDL cholesterol and 10-year ASCVD risk – and talk about the benefits of lifestyle therapy, potential drug interactions and costs. Patient preferences and values ​​should be integrated into this shared decision model.

In adult patients with primary hypercholesterolaemia aged 40 to 75 without diabetes and with LDL cholesterol ≥ 190 mg / dL, physicians should start with high-intensity statin without calculating 10-year ASCVD I risk. If the LDL cholesterol level remains 100 mg / dL or higher, ezetimibe (Class IIa) should be added. When treating patients with primary hypercholesterolaemia with statin and ezetimibe (Class IIb), PCSK9 inhibitor should be considered if LDL levels are still 100 mg / dL or higher.

It is important to emphasize that the new cholesterol guidelines also recommend the treatment of elderly and younger people, as appropriate. In addition, compared to the previous version, lipid monitoring recommends from 4 to 12 weeks after initiation of statin therapy to verify the adherence and treatment effect as well as ongoing monitoring from 3 to 12 months after,

(b) "gray" area, ie medium risk
"The gray area or middle-class area now has much more emphasis on guidance," Blumenthal said. "The 10% -15% ASCVD risk score does not automatically store statins, but it should lead to more detailed discussion, and I think it's an important step forward for these guidelines."

To help the shared decision-making process, the document specifies a series of risk-raising factors that are not included in the risk calculator and, if present, "may ask us to move forward and prescribe the statin if the patient is," said Lloyd- Jones.

Risk factors include:

  • LDL-C equal to or greater than 160 mg / dL or higher;
  • C-reactive protein (high sensitivity test) 2.0 mg / l or higher, apolipoprotein B 130 mg / dL or higher or elevated lipoprotein (a);
  • ankle-arm index less than 0.9;
  • comorbid conditions such as metabolic syndrome; chronic kidney disease (CKD); chronic inflammatory disorders such as rheumatoid arthritis, lupus or HIV; or early menopause;
  • family history of ASCVD early;
  • chronic risk of elevated ASCVD.

The paper states that for patients at risk of ASCVD, ie at a 10-year risk of 5% to less than 7.5%, the presence of high-risk enhancers would favor treatment with a class IIb recommendation. Such amplifiers would prefer statins with Class I recommendation for medium risk subjects ranging from 7.5% to less than 20%. For high-risk patients (ie score 20% or higher), high-intensity statins are preferred by Class 1 recommendations.

c) Screening of coronary artery calcium (CAC)
It is important to emphasize that "if after this discussion the doctor and the patient are still not convinced or if the patient really wants further confirmation, we have proposed specific recommendations on the use of coronary artery calcium screening (CAC)," said Lloyd-Jones. CAC imaging would be an option primarily for patients at moderate risk. If the CAC score is 0, "as it would be about 50% of these people, then we say that it is wise to avoid the statin," he said.

For patients with a CAC score of at least 100 Agatston units adjusted by age and gender at 75. percentile, "we very clearly say that this group is benefiting from statin therapy." We do not only think that they are at higher risk, but their football results suggest that they have a significant burden of atherosclerosis. "

If the CAC score is in an indefinite range between 1 and 99 units of Agatston, it could be a statin start or a coronary calcium test repeated at least two years later. "And if the score changed rapidly, it would be a sign that we could take more statin," Lloyd-Jones said.

According to the LG study, patients with a moderate-risk risk defined as 10 years of risk between 7.5% and 19.9% ​​and CAC score zero, statin therapy may be delayed or delayed if the patient is not smoker, has no diabetes or has a strong family history of ASCVD (Class IIa).

On the other hand, the CAC score between 1 and 100 shifts the balance to statin treatment (Class IIa). Other risk factors, such as persistent elevated LDL cholesterol (=> 160 mg / dL), family history of ASCVD, metabolic syndrome, chronic kidney disease, and inflammatory disorders, should start with a transient risk of statin therapy.

President ACC Mary Norine WalshThe Center for the Heart of St. Vincent at Indianapolis has emphasized that shared decision making is particularly important in patients who decide on permanent medical therapy.

He also emphasized the importance of risk assessment using group cohort equations and that patients should not promptly perform CAC tests on their own initiative. "What people have done in cities around the world is announcing CAC results," Walsh said, and noted that he even saw special or discounts for mothers and dads on Mother's Day or Father's Day. "You do not start a CAC score: you start with an individual risk and then you decide."

d) Diabetes without clinical ASCVD
The article recommends that all patients with diabetes aged 40 to 75 years with LDL-C levels of 70 mg / dL or higher use mild intensity statins and do not need a 10-year risk assessment. ASCVD. High-intensity statin should be considered in patients with multiple risk factors.

The document offers some flexibility for diabetic patients, says Blumenthal: "If the patient is still not sure whether to continue taking statins in life, it's certainly a reasonable part of the risk discussion to test the change in lifestyle that is intensifying, and then see if gained HbA1c from 7% to 6.5% or less: so even with body weight loss and exercise, their lipids may also be improved. "

e) Secondary prevention: ASCVD clinic
In the area of ​​secondary prevention, class I indications are now to reduce LDL cholesterol levels by 50% or more with high-intensity statin (atorvastatin 40-80 mg and rosuvastatin 20-40 mg) or a dose of maximally tolerated statin in all patients with ASCVD.

In patients with high ASCVD risk such as patients with a history of multiple events or higher ASCVD and higher risk status and LDL cholesterol => 70 mg / dL, it is recommended that ezetimibe add maximum statin therapy to lower LDL levels below the threshold (Class IIa). If LDL still remains = /> 70 mg / dL, the addition of a PCSK9 inhibitor such as alirocumab or evolocumab is adequate (Class IIa), although the guidelines state that the long-term safety of PCSK9 inhibitors is not known.

These guidelines now contain a threshold for the use of statin drugs in those at high risk. In other words, the strongest reduction in LDL is reserved for those who have the highest risk.

f) Primary severe hypercholesterolaemia or FH
For patients in this category who have an LDL-C of more than 190 mg / dL, "there is no need to count the risk for 10 years, we know they need treatment, so statin therapy is the best for everyone," said Lloyd-Jones.

If there is no 50% reduction in LDL-C that remains above 100 mg / dL, it is reasonable to first treat ezetimibe and then consider PCSK9 inhibitors if it has not reached the threshold.

g) Non-pharmacological treatment
The guideline document promotes a "healthy lifestyle of the heart during life" as a basis for all its more detailed sections on risks and treatment regimens.

"Even if you start taking cholesterol or antihypertensive medication, or both, the clinician should really highlight ways to further improve the lifestyle of the patient over the next three to six months," Blumenthal concluded.


Grundy SM, Stone NJ, Bailey AL et al. 2018 Guidelines for Cholesterol Control in the Blood: American College of Cardiology / American Heart Association, Circulation, 2018 October 10: 10.1161 / CIR.0000000000000625. [Epub ahead of print],

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