10-Year ASCVD Risk
3%
calculated risk
3%
risk with optimal risk factors
This calculator only provides 10-year risk estimates for individuals 40 to 70 years of age.
Lifetime ASCVD Risk
3%
calculated risk
3%
risk with optimal risk factors
Lifetime Risk Calculator only provides lifetime risk estimates for individuals 20 to 59 years of age.

ASCVD Risk Estimator

Intended for patients with LDL-C < 190 mg/dL (4.92 mmol/L), without ASCVD, not on LDL-C lowering therapy

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Demographics

Age must be between 20-79
Note: These estimates may underestimate the 10-year and lifetime risk for persons from some race/ethnic groups, especially American Indians, some Asian Americans (e.g., of south Asian ancestry), and some Hispanics (e.g., Puerto Ricans), and may overestimate the risk for others, including some Asian Americans (e.g., of east Asian ancestry) and some Hispanics (e.g., Mexican Americans). Because the primary use of these risk estimates is to facilitate the very important discussion regarding risk reduction through lifestyle change, the imprecision introduced is small enough to justify proceeding with lifestyle change counseling informed by these results.

Labs

Value must be between 130 - 320
Value must be between 3.367 - 8.288
Value must be between 20 - 100
Value must be between 0.518 - 2.59
Value must be between 90-200

Personal History

10-Year ASCVD Risk
3%
calculated risk
3%
risk with optimal risk factors
This calculator only provides 10-year risk estimates for individuals 40 to 70 years of age.
Lifetime ASCVD Risk
3%
calculated risk
3%
risk with optimal risk factors
Lifetime Risk Calculator only provides lifetime risk estimates for individuals 20 to 59 years of age.

Recommendation Based on the data entered (assuming LDL-C < 190 mg/dL (4.92 mmol/L), no ASCVD, not on LDL-C lowering therapy)

Lifestyle Recommendations

AHA/ACC guidelines stress the importance of lifestyle modifications to lower cardiovascular disease risk. This includes eating a heart-healthy diet, regular aerobic exercises, maintenance of desirable body weight and avoidance of tobacco products.


Inputs

  • Sex:
  • Age:
  • Race:
  • Total Cholesterol: mg/dL mmol/L
  • HDL-Cholesterol: mg/dL mmol/L
  • Systolic Blood Pressure: mm Hg
  • Diabetes:
  • Smoker:
  • Treatment for Hypertension:

Note: These estimates may underestimate the 10-year and lifetime risk for persons from some race/ethnic groups, especially American Indians, some Asian Americans (e.g., of south Asian ancestry), and some Hispanics (e.g., Puerto Ricans), and may overestimate the risk for others, including some Asian Americans (e.g., of east Asian ancestry) and some Hispanics (e.g., Mexican Americans).
Because the primary use of these risk estimates is to facilitate the very important discussion regarding risk reduction through lifestyle change, the imprecision introduced is small enough to justify proceeding with lifestyle change counseling informed by these results.

Disclaimer

The results and recommendations provided by this application are intended to inform but do not replace clinical judgment. Therapeutic options should be individualized and determined after discussion between the patient and their care provider.

About the Application

When was this app last updated?

November 2018

How can I provide feedback?

Click here to fill out our feedback survey

How is this app intended to be used?

This Risk Estimator is intended as a companion tool to the 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk and the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. This Risk Estimator enables health care providers and patients to estimate 10-year and lifetime risks for atherosclerotic cardiovascular disease (ASCVD), defined as coronary death or nonfatal myocardial infarction, or fatal or nonfatal stroke, based on the Pooled Cohort Equations and lifetime risk prediction tools.

The Risk Estimator is intended for use in those without ASCVD with a LDL-cholesterol <190 mg/dL.The information required to estimate ASCVD risk includes age, sex, race, total cholesterol, HDL cholesterol, systolic blood pressure, blood pressure lowering medication use, diabetes status, and smoking status.

The results and recommendations provided by this application are intended to inform but do not replace clinical judgment. Therapeutic options should be individualized and determined after discussion between the patient and their care provider.

How are the estimates in this app calculated?

10-Year ASCVD Risk Estimates

Estimates of 10-year risk for ASCVD are based on data from multiple community-based populations and are applicable to African-American and non-Hispanic white men and women 40 through 79 years of age.

For other ethnic groups, we recommend use of the equations for non-Hispanic whites, though these estimates may under- or overestimate risk for persons from some race/ethnic groups.

Lifetime ASCVD Risk Estimates

Estimates of lifetime risk for ASCVD are provided for adults 20 through 59 years of age and are shown as the lifetime risk for ASCVD for a 50-year old without ASCVD who has the risk factor values entered into the Estimator. The estimates of lifetime risk are most directly applicable to non-Hispanic whites. We recommend the use of these values for other race/ethnic groups, though as mentioned above, these estimates may represent under- and over-estimates for persons of various ethnic groups. Because the primary use of these lifetime risk estimates is to facilitate the very important discussion regarding risk reduction through lifestyle change, the imprecision introduced is small enough to justify proceeding with lifestyle change counseling informed by these results.

10-Year Risk Estimates that Exceed Lifetime Risk Estimates

In rare cases, 10-year risks may exceed lifetime risks given that the estimates come from different approaches. The reported estimate of lifetime risk is based on assigning each person into one of 5 mutually exclusive sex-specific groups, as per Lloyd-Jones et al., Circulation 2006; 113(6):791-8. Within each of the 5 groups, each person receives the same lifetime risk estimate. In other words, using this approach, there are only 5 possible lifetime risk estimates reported for men and only 5 possible lifetime risk estimates reported for women. In some cases, the average risk for the group will underestimate the individual’s true lifetime risk. This feature of lifetime risk estimation will result in the estimated lifetime risk being less than the estimated 10-year risk. In these cases, the 10-year risk should be the primary focus for the risk discussion and risk reduction efforts.

Application Credits

2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk

David C. Goff, MD, PhD, FACP, FAHA Donald M. Lloyd-Jones, MD, ScM, FACC, FAHA Glen Bennett, MPH Christopher J. O'Donnell, MD, MPH Sean Coady, MS Jennifer Robinson, MD, MPH, FAHA Ralph B. D'Agostino,Sr, PhD, FAHA J. Sanford Schwartz, MD Raymond Gibbons, MD, FACC, FAHA Susan T. Shero, MS, RN Philip Greenland, MD, FACC, FAHA Sidney C. Smith, MD, FACC, FAHA Daniel T. Lackland, DrPH, FAHA Paul Sorlie, PhD Daniel Levy, MD Neil J. Stone, MD, FACC, FAHA Peter W.F. Wilson, MD, FAHA

2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults

Neil J. Stone, MD, MACP, FAHA, FACC Jennifer Robinson, MD, MPH, FAHA Alice H. Lichtenstein, DSc, FAHA C. Noel Bairey Merz, MD, FAHA, FACC Donald M. Lloyd-Jones, MD, ScM, FACC, FAHA Conrad B. Blum, MD, FAHA Patrick McBride, MD, MPH, FAHA Robert H. Eckel, MD, FAHA J. Sanford Schwartz, MD Anne C. Goldberg, MD, FACP, FAHA Susan T. Shero, MS, RN David Gordon, MD Sidney C. Smith Daniel Levy, MD Karol Watson, MD, PhD, FACC, FAHA Peter W.F. Wilson, MD, FAHA

2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults

Michael D. Jensen, MD Donna H. Ryan, MD Caroline M. Apovian, MD, FACP Catherine M. Loria, PhD, FAHA Jamy D. Ard, MD Barbara E. Millen, DrPH, RD Anthony G. Comuzzie, PhD Cathy A. Nonas, MS, RD Karen A. Donato, SM F. Xavier Pi-Sunyer, MD, MPH Frank B. Hu, MD, PhD, FAHA June Stevens, PhD Van S. Hubbard, MD, PhD Victor J. Stevens, PhD John M. Jakicic, PhD Thomas A. Wadden, PhD Robert F. Kushner, MD Bruce M. Wolfe, MD Susan Z. Yanovski, MD

2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk

Robert H. Eckel, MD, FAHA John M. Jakicic, PhD Jamy D. Ard, MD Nancy Houston Miller, RN, BSN, FAHA Van S. Hubbard, MD, PhD Cathy A. Nonas, MS, RD Janet M. de Jesus, MS, RD Frank M. Sacks, MD, FAHA I-Min Lee, MD, ScD Sidney C. Smith Alice H. Lichtenstein, DSc, FAHA Laura P. Svetkey, MD, MHS Catherine M. Loria, PhD, FAHA Thomas W. Wadden, PhD Barbara E. Millen, DrPH, RD, FADA Susan Z. Yanovski, MD

Application Development Credits

Concepts for this application adapted from the Cardiac Risk Assist App developed by Tin T.D. Nguyen, MD.

Special Thanks to the ACC Best Practice Quality Improvement Subcommittee, whose members have provided content development and review

Disclaimer

By using this application and its content, you accept and agree to be bound by the following terms and conditions.

This Application was produced after careful consideration of the scientific and medical knowledge and the evidence available at the time of publication. The results and recommendations provided by this application are not intended to, and should not, replace clinical judgment of the care provider. Further, the material is not intended to present the only, or necessarily the best, methods or procedures for the medical situation, but rather is intended to represent an approach, view, statement, or opinion. The content in this product is presented as an educational service intended for licensed healthcare professionals. Therapeutic options should be determined after discussion between the patient and their care provider.

You hereby agree to indemnify, defend, and hold ACCF, its directors, officers, shareholders, parents, subsidiaries, affiliates, agents, and licensors harmless from and against any and all liability, losses, damages, and costs, including, without limitation, reasonable attorney’s fees and costs, incurred in connection with any claim arising from your use of this application or its content.

©The American College of Cardiology Foundation 2016

All Rights Reserved. The content of this app has been published for personal and educational use only. No commercial use is authorized.

Understanding Cardiovascular Risk

10-Year ASCVD Risk

  • The 10-year calculated ASCVD risk is a quantitative estimation of absolute risk based upon data from representative population samples.
  • The 10-year risk estimate for "optimal risk factors" is represented by the following specific risk factor numbers for an individual of the same age, sex and race: Total cholesterol of ≤ 170 mg/dL, HDL-cholesterol of ≥ 50 mg/dL, untreated systolic blood pressure of ≤ 110 mm Hg, no diabetes history, and not a current smoker.
  • While the risk estimate is applied to individuals, it is based on group averages.
  • Just because two individuals have the same estimated risk does not mean that they will or will not have the same event of interest.
  • Example: If the 10-year ASCVD risk estimate is 10%, this indicates that among 100 patients with the entered risk factor profile, 10 would be expected to have a heart attack or stroke in the next 10 years.

Lifetime ASCVD Risk

  • The lifetime calculated ASCVD risk represents a quantitative estimation of absolute risk for a 50 year old man or woman with the same risk profile.
  • This estimation of risk is based on the grouping of risk factor levels into 5 strata.
    • All risk factors are optimal*
    • ≥1 risk factors are not optimal†
    • ≥1 risk factors are elevated‡
    • 1 major risk factor§
    • ≥2 major risk factors§
  • The division of lifetime risk by these 5 strata leads to thresholds in the data with large apparent changes in lifetime risk estimates.
  • Example: An individual that has all optimal risk factors except for a systolic blood pressure of 119 mm Hg has a lifetime ASCVD risk of 5%. In contrast, a similar individual that has all optimal risk factors except for a systolic blood pressure of 120 mm Hg has a lifetime ASCVD risk of 36%. This substantial difference in lifetime risk is due to the fact that they are in different stratum.

*Optimal risk levels for lifetime risk are represented by the simultaneous presence of all of the following: Untreated total cholesterol <180 mg/dL, untreated blood pressure <120/<80 mm Hg, no diabetes history, and not a current smoker

†Nonoptimal risk levels for lifetime risk are represented by 1 or more of the following: Untreated total cholesterol of 180 to 199 mg/dL, untreated systolic blood pressure of 120 to 139 mm Hg or diastolic blood pressure of 80 to 89 mm Hg, and no diabetes history and not a current smoker

‡Elevated risk levels for lifetime risk are represented by 1 or more of the following: Untreated total cholesterol of 200 to 239 mg/dL, untreated systolic blood pressure of 140 to 159 mm Hg or diastolic blood pressure of 90 to 99 mm Hg, and no diabetes history and not a current smoker

§Major risk levels for lifetime risk are represented by any of the following: Total cholesterol ≥240 mg/dL or treated, systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥100 mm Hg or treated, or diabetes, or current smoker

Lifestyle Recommendations

Diet recommendations

Diet recommendations for LDL-C lowering

  1. Consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils and nuts; and limits intake of sweets, sugar-sweetened beverages, and red meats. (I A)
    • Adapt this dietary pattern to appropriate calorie requirements, personal and cultural food preferences, and nutrition therapy for other medical conditions (including diabetes mellitus).
    • Achieve this pattern by following plans such as the DASH dietary pattern, the USDA Food Pattern, or the AHA Diet.
  2. Aim for a dietary pattern that achieves 5-6% of calories from saturated fat. (I A)
  3. Reduce percent of calories from saturated fat. (I A)
  4. Reduce percent of calories from trans fat. (I A)

Diet recommendations for blood pressure lowering

  1. Consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils and nuts; and limits intake of sweets, sugar-sweetened beverages, and red meats. (I A)
    • Adapt this dietary pattern to appropriate calorie requirements, personal and cultural food preferences, and nutrition therapy for other medical conditions (including diabetes mellitus).
    • Achieve this pattern by following plans such as the DASH dietary pattern, the USDA Food Pattern, or the AHA Diet.
  2. Lower sodium intake. (I A)
  3. Consume no more than 2400 mg of sodium per day. (I B)

Weight Management Recommendations

Diets for weight loss

  1. Prescribe a diet to achieve reduced calorie intake for obese or overweight individuals who would benefit from weight loss, as part of a comprehensive lifestyle intervention with 1 of the following (I A):
    • 1200-1500 kcal/day for women and 1500-1800 kcal/day for men.
    • 500-750 kcal/day energy deficit.
    • Use one of the evidence-based diets that restricts certain food types (e.g., high-carbohydrate foods, low-fiber foods, or high-fat foods) in order to create an energy deficit by reduced food intake.
  2. Prescribe a calorie-restricted diet for obese or overweight individuals who would benefit from weight loss, based on the patient's preferences and health status, and preferably refer to a nutrition professional for counseling. (I A)

Lifestyle interventions and counseling for weight loss

  1. Advise participation in a comprehensive lifestyle program that assists participants in adhering to a lower calorie diet and increasing physical activity through the use of behavioral strategies. (I A)
  2. Prescribe on site, high-intensity (i.e., >14 sessions in 6 months) comprehensive weight loss interventions provided in individual or group sessions by a trained interventionist. (I A)
  3. Consider prescription of electronically delivered weight loss programs (including by telephone) that includes personalized feedback from a trained interventionist, recognizing that it may result in smaller weight loss than face-to-face interventions. (IIa A)
  4. Consider some commercial-based programs that provide comprehensive lifestyle interventions, provided there is peer-reviewed published evidence of their safety and efficacy. (IIa A)
  5. Consider a very low calorie diet (<800 kcal/day) only in limited circumstances and only when provided by trained practitioners in a medical care setting where medical monitoring and high intensity lifestyle intervention can be provided. (IIa A)
  6. Advise individuals who have lost weight to participate long term (>1 year) in a comprehensive weight loss maintenance program. (I A)
  7. Prescribe face-to-face or telephone-delivered weight loss maintenance programs that provide regular contact (> monthly) with a trained interventionist who helps participants engage in high levels of physical activity (i.e., 200-300 minutes/week), monitor body weight regularly (> weekly), and consume a reduced-calorie diet (need to lower body weight). (I A)

Selection criteria for bariatric surgical treatment of obesity

  1. Advise adults with a BMI ≥40 kg/m2 or BMI ≥35 kg/m2 with obesity-related co-morbid conditions who are motivated to lose weight and who have not responded to behavioral treatment with or without pharmacotherapy with sufficient weight loss to achieve targeted health outcome goals that bariatric surgery may be an appropriate option to improve health and offer referral to an experienced bariatric surgeon for consultation and evaluation. (IIa A)

Physical Activity Recommendations

Physical activity recommendations for modifying lipids and blood pressure lowering

  1. Advise adults to engage in aerobic physical activity to reduce LDL-cholesterol, non-HDL-cholesterol, and blood pressure. (IIa A)
    • Frequency: 3-4 sessions a week
    • Intensity: Moderate to vigorous
    • Duration: 40 minutes on average

Physical activity recommendations for secondary prevention*

  1. Aerobic exercise
    • Frequency: 3-5 days/week
    • Intensity: 50-80% of exercise capacity
    • Duration: 20-60 minutes
    • Modalities: Examples include walking, treadmill, cycling, rowing, stair climbing, and arm/leg ergometry
  2. Resistance exercise
    • Frequency: 2-3 days/week
    • Intensity: 10-15 repetitions/set to moderate fatigue
    • Duration: 1-3 sets of 8-10 upper and lower body exercises
    • Modalities: Examples include calisthenics, elastic bands, cuff/hand weights, dumbbells, free weights, wall pulleys, and weight machines
*Balady GJ et al. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a Scientific Statement of the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation 2007;115:2675-2682

Tobacco Cessation Recommendations

5 R's for patients not ready to quit

  1. Relevance—Encourage the patient to indicate why quitting is personally relevant.
  2. Risks—Ask the patient to identify potential negative consequences of tobacco use.
  3. Rewards—Ask the patient to identify potential benefits of stopping tobacco use.
  4. Roadblocks—Ask the patient to identify barriers or impediments to quitting.
  5. Repetition—The motivational intervention should be repeated every time an unmotivated patient has an interaction with a clinician. Tobacco users who have failed in previous quit attempts should be told that most people make repeated quit attempts before they are successful.

5 A's for patients that are ready to quit

  1. Ask—Systematically identify all tobacco users at every visit.
  2. Advise—Strongly urge all smokers to quit.
  3. Assess—Identify smokers willing to make a quit attempt.
  4. Assist—Aid the patient in quitting.
  5. Arrange—Schedule follow-up contact.

ASCVD Risk Enhancing Factors

ASCVD Risk Enhancing Factors
  • Family history of premature ASCVD; (males <55 years; females <65 years)
  • Primary hypercholesterolemia (LDL-C 160-189 mg/dL (4.1- 4.8 mmol/L); non-HDL-C 190-219 mg/dL (4.9-5.6 mmol/L).*
  • Metabolic syndrome (increased waist circumference, elevated TG (>175 mg/dL (>2 mmol/L ), BP, glucose, low HDL-C
    (<40 in men, <50 in women) are factors; tally of 3 makes the diagnosis)
  • Chronic kidney disease (eGFR 15- 59 ml/min per1.73 m2 with or without albuminuria) not treated with dialysis or kidney transplantation)
  • Chronic inflammatory conditions such as psoriasis, rheumatoid arthritis (RA) or human immunodeficiency virus (HIV)/ acquired immunodeficiency syndrome (AIDS)
  • History of premature menopause (before age 40) and history of pregnancy-associated conditions that increase later ASCVD risk such as pre-eclampsia
  • High-risk ethnicities (e.g. South Asian ancestry)
  • Lipid/Biomarkers: Associated with increased ASCVD risk
    • Persistently* elevated, primary hypertriglyceridemia;( ≥ 175-500 mg/dl);
    • If measured:
      • High-sensitivity C-reactive protein - (≥2.0 mg/L)
      • Elevated lipoprotein (a) - ≥50 mg/dl or ≥125 nmol/L, but especially in those with higher Lp(a) values and if used in women, only in the presence of hypercholesterolemia
      • Elevated apolipoprotein B (apo B) ≥130 mg/dl

* Optimally, three determinations

Ethnicity Issues in Risk Evaluation

EVALUATION

ASCVD Issues informed by ethnicity

Lipid issues informed by ethnicity

Metabolic issues informed by ethnicity

RISK DECISIONS

Pooled Cohort Equations (PCE)

Coronary Artery Calcium (CAC) Score

TREATMENT

Lifestyle counseling (Utilize principles of Mediterranean & DASH diets)

Intensity of statin therapy and response to LDL-C lowering

Safety

*The term Asian characterizes a diverse population group. Individuals from Bangladesh, India, Nepal, Pakistan and Sri Lanka make up the majority of the South Asian group. Individuals from Japan, Korea, and China make up the majority of the East Asian group.

The term Hispanics/Latinos in the United States characterizes a diverse population group. This includes white, black, and Native American races. Their ancestry goes from Europe to America, including among these, individuals from the Caribbean, Mexico, Central and South America

Secondary Prevention - Patients with Clinical ASCVD

secondary prevention

LDL-C Treatment Suggestions for Younger Patients

The following is a summary of some of the key suggestions for primary prevention in patients age 20-39 provided by the 2018 ACC/AHA Cholesterol Guideline.

  • In patients without phenotypically severe hypercholesterolemia:
    - Expert consensus discussion suggests beginning risk assessment by estimating lifetime risk. Multiple risk factors indicate lifestyle intervention.
  • In patients with persistent, moderate hypercholesterolemia (LDL-C 160-189 mg/dL (4.1-4.8 mmol/L)):
    - Expert consensus discussion suggests that lifestyle intervention is indicated, and long-term statin therapy would be beneficial, especially for those with other risk enhancing factors.
  • In patients with severe hypercholesterolemia (LDL-C >190 mg/dL (≥4.9 mmol/L)):
    - Expert consensus discussion suggests lifestyle intervention is indicated.
    - Guideline also recommends maximally tolerated therapy statin therapy. (I, B)
    - If recommended LDL-C reduction of > 50% is not achieved, then possible addition of non-statin therapies is also recommended.
  • In patients with diabetes either of long duration (≥10 years of T2D, ≥20 years of T1D), and/or albuminuria (≥30 mcg albumin/mg creatinine), eGFR <60 ml/min/m2, retinopathy, neuropathy:
    - Expert consensus discussion suggests lifestyle intervention is indicated.
    - Guideline recommends that it may be reasonable to initiate statin therapy. (IIb, C)

Discussion Checklist for Therapy Initiation

Checklist Item Recommendation
ASCVD Risk Assessment
  • Assign to statin treatment group; use ASCVD risk estimator plus
    • In lower risk primary prevention adults 40-75 years with LDL-C ≥70 mg/dL(≥1.8 mmol/L) . Not needed in secondary prevention, LDL-C ≥190 mg/dL (≥4.9 mmol/L) and those 40-75 years with diabetes.
  • Assess other patient characteristics which influence risk. See Risk Enhancing Factors
  • Assess calcium artery calcium if risk decision uncertain and additional information is needed to clarify ASCVD risk
    • Use decision tools to explain risk (such as this app, Mayo Clinic Statin Choice Decision Aid)
Lifestyle Modifications
  • Review lifestyle habits (diet, physical activity, weight/BMI, tobacco use)
  • Endorse a healthy lifestyle and provide relevant advice/materials/referrals (CardioSmart, AHA Life's Simple 7, NLA Patient Tear Sheets, PCNA Clinicians' Lifestyle Modification Toolbox, cardiac rehab, dietitian, smoking cessation program)
Potential Net-Clinical Benefit of Pharmacotherapy
  • Recommend statins as first-line therapy
  • Consider the combination of statin and non-statin therapy in select patients
  • Discuss potential risk reduction from lipid-lowering therapy
  • Discuss the potential for adverse effects/drug-drug interactions
Cost Considerations
  • Discuss potential out-of-pocket cost of therapy to the patient (e.g., insurance plan coverage, tier level, copayment)
Shared Decision Making
  • Encourage patient to verbalize what was heard (personal ASCVD risk, available options and their risk/benefit)
  • Invite the patient to ask questions, express values/preferences, state ability to adhere to lifestyle changes and medications
  • Collaborate with the patient to determine therapy and follow-up plan

Using CAC Score to Inform Decisions

Specific CAC Guideline Recommendations

COR   LOE   Recommendations
IIa B-NR In intermediate-risk or selected borderline-risk adults, if the decision about statin usage remains uncertain, it is reasonable to use a coronary artery calcium (CAC) score in the decision to withhold, postpone or initiate statin therapy.
IIa B-NR In intermediate-risk adults or selected borderline-risk adults in whom a CAC score is measured for the purpose of making a treatment decision, AND
  • If CAC=0, it is reasonable to withhold statin therapy and reassess CAC score in 5-10 years, as long as higher risk conditions are absent (diabetes mellitus, family history of premature CHD, cigarette smoking)
  • If CAC= 1 to 99, it is reasonable to initiate statin therapy for patients ≥ 55 years of age;
  • If CAC≥ 100 or CAC ≥ 75th percentile, it is reasonable to initiate statin therapy.
IIb B-R In adults 76-80 years of age with LDL-C of 70 to 189 mg/dL (1.7 to 4.8 mmol/L), it may be reasonable to measure coronary artery calcium (CAC) to reclassify those with CAC = 0 to avoid statin therapy.

Specific CAC Score Ethnicity Considerations

  Ethnic/racial groupings
  Asian-Americans* Hispanic/Latino-Americans African-Americans Comments:
Coronary Artery Calcium (CAC) Score In terms of CAC burden, South Asian men were similar to non-Hispanic white men, but higher CAC when compared to African Americans, Latinos and Chinese Americans. South Asian women had similar CAC to whites and other ethnic women, although CAC burden higher in older age. CAC predicts similarly in whites and those who identify as Hispanic/Latino. In MESA (Multi-Ethnic Study of Atherosclerosis), CAC score was highest in Caucasian and Hispanic men, with African-Americans having significantly lower prevalence and severity of CAC. Risk factor differences in MESA between ethnicities didn’t fully explain variability in CAC However, CAC predicted ASCVD events over and above traditional risk factors in all ethnicities.

*The term Asian characterizes a diverse population group. Individuals from Bangladesh, India, Nepal, Pakistan and Sri Lanka make up the majority of the South Asian group. Individuals from Japan, Korea, and China make up the majority of the East Asian group.

The term Hispanics/Latinos in the United States characterizes a diverse population group. This includes white, black, and Native American races. Their ancestry goes from Europe to America, including among these, individuals from the Caribbean, Mexico, Central and South America

Groups that Benefit from Statin Therapy

1. Secondary Prevention: Clinical ASCVD

Clinical ASCVD includes acute coronary syndromes, history of MI, stable or unstable angina, coronary or other arterial revascularization, stroke, TIA, or peripheral arterial disease presumed to be of atherosclerotic origin.

High-intensity statin therapy should be initiated or continued as first-line therapy in women and men ≤75 years of age who have clinical ASCVD, unless contraindicated. (I A)

In individuals with clinical ASCVD in whom high-intensity statin therapy would otherwise be used, when high-intensity statin therapy is contraindicated or when characteristics predisposing to statin-associated adverse effects are present, moderate-intensity statin should be used as the second option if tolerated. (I A)

In individuals with clinical ASCVD >75 years of age, it is reasonable to evaluate the potential for ASCVD risk-reduction benefits and for adverse effects, drug-drug interactions and to consider patient preferences, when initiating a moderate- or high-intensity statin. It is reasonable to continue statin therapy in those who are tolerating it. (IIa B)

2. Primary Prevention: LDL-C ≥190 mg/dL

Individuals with LDL-C ≥190 mg/dL or triglycerides ≥500 mg/dL should be evaluated for secondary causes of hyperlipidemia. (I B)

Adults ≥21 years of age with primary LDL-C ≥190 mg/dL should be treated with high-intensity statin therapy unless contraindicated. For individuals unable to tolerate high-intensity statin therapy, use the maximum tolerated statin intensity. (I B)

For individuals ≥21 years of age with an untreated primary LDL-C ≥190 mg/dL, it is reasonable to intensify statin therapy to achieve at least a 50% LDL-C reduction. (IIa B)

For individuals ≥21 years of age with an untreated primary LDL-C ≥190 mg/dL, after the maximum intensity of statin therapy has been achieved, addition of a nonstatin drug may be considered to further lower LDL-C. Evaluate the potential for ASCVD risk reduction benefits, adverse effects, drug-drug interactions, and consider patient preferences. (IIb C)

3. Primary Prevention: Diabetes and aged 40 to 75 years with LDL-C between 70 - 189 mg/dL

Moderate-intensity statin therapy should be initiated or continued for adults 40 to 75 years of age with diabetes mellitus. (I A)

High-intensity statin therapy is reasonable for adults 40 to 75 years of age with diabetes mellitus with a ≥7.5% estimated 10-year ASCVD risk unless contraindicated. (IIa B)

In adults with diabetes mellitus, who are <40 or >75 years of age, it is reasonable to evaluate the potential for ASCVD benefits and for adverse effects, for drug-drug interactions, and to consider patient preferences when deciding to initiate, continue, or intensify statin therapy. (IIa C)

4. Primary Prevention: No diabetes and estimated 10-year ASCVD risk of ≥7.5% who are between 40 to 75 years of age with LDL-C between 70 - 189 mg/dL

The Pooled Cohort Equations should be used to estimate 10-year ASCVD risk for individuals with LDL-C 70 to 189 mg/dL without clinical ASCVD to guide initiation of statin therapy for the primary prevention of ASCVD. (I B)

Before initiating statin therapy for the primary prevention of ASCVD in adults with LDL-C 70 - 189 mg/dL without clinical ASCVD or diabetes it is reasonable for clinicians and patients to engage in a discussion which considers the potential for ASCVD risk reduction benefits and for adverse effects, for drug-drug interactions, and patient preferences for treatment. (IIa C)

Adults 40 to 75 years of age with LDL-C 70 to 189 mg/dL, without clinical ASCVD or diabetes and an estimated 10-year ASCVD risk ≥7.5% should be treated with moderate- to high-intensity statin therapy. (I A)

It is reasonable to offer treatment with a moderate-intensity statin to adults 40 to 75 years of age, with LDL-C 70 to 189 mg/dL, without clinical ASCVD or diabetes and an estimated 10-year ASCVD risk of 5% to <7.5%. (IIa B)

In adults with LDL-C <190 mg/dL who are not otherwise identified in a statin benefit group, or for whom after quantitative risk assessment a risk-based treatment decision is uncertain, additional factors may be considered to inform treatment decision making. In these individuals, statin therapy for primary prevention may be considered after evaluating the potential for ASCVD risk reduction benefits, adverse effects, drug-drug interactions, and discussion of patient preferences. (IIb C)

Additional Factors

These factors may include:

Statin benefit may be less clear in other groups; additional factors may be considered to inform treatment decision making.

  1. 5 to <7.5% 10-year ASCVD risk
  2. Primary LDL-C ≥160 mg/dL or other evidence of genetic hyperlipidemias
  3. Family history of premature ASCVD
  4. High sensitivity C-reactive protein ≥2 mg/L
  5. Coronary artery calcium score ≥300 Agatston units or ≥75th percentile for age, sex, and ethnicity
  6. Ankle-brachial index <0.9
  7. Lifetime risk of ASCVD

General Populations Recommendation Summary

Primary Prevention Recommendations for Adults 40-75 Years LDL 70-189 mg/dL (1.7 - 4.8 mmol/L)
COR   LOE   Recommendations
I A 1. In adults at intermediate-risk, statin therapy reduces risk of ASCVD and in the context of a risk discussion, if a decision is made for statin therapy, a moderate- intensity statin should be recommended.
I A 2. In intermediate risk patients, LDL-C levels should be reduced by ≥ 30%, and for optimal ASCVD risk reduction, especially in high-risk patients, achieve LDL-C reductions of ≥ 50%.
I B-NR 3. For the primary prevention of clinical ASCVD* in adults 40 to 75 years of age without diabetes and with LDL-C 70 to 189 mg/dL (1.7 to 4.8 mmol/L), the 10-year ASCVD risk of a first "hard" ASCVD event (fatal and non-fatal MI or stroke) should be estimated using the race and sex-specific Pooled Cohort Equations (PCE) and adults should be categorized as low risk (<5%), borderline risk (5 to <7.5%), intermediate-risk (≥7.5 to <20%), and high-risk (≥20%).
I B-NR 4. Clinicians and patients should engage in a risk discussion that considers risk factors, adherence to healthy lifestyle, the potential for ASCVD risk-reduction benefits and the potential for adverse effects and drug–drug interactions, as well as patient preferences for an individualized treatment decision.
IIa B-R 5. In intermediate-risk adults, risk-enhancing factors favor initiation or intensification of statin therapy.
IIa B-NR 6. In intermediate-risk or selected borderline-risk adults, if the decision about statin usage remains uncertain, it is reasonable to use a coronary artery calcium (CAC) score in the decision to withhold, postpone or initiate statin therapy.
IIa B-NR 7. In intermediate-risk adults or selected borderline-risk adults in whom a CAC score is measured for the purpose of making a treatment decision, AND
  • If CAC=0, it is reasonable to withhold statin therapy and reassess CAC score in 5-10 years, as long as higher risk conditions are absent (diabetes mellitus, family history of premature CHD, cigarette smoking)
  • If CAC= 1 to 99, it is reasonable to initiate statin therapy for patients ≥ 55 years of age;
  • If CAC≥ 100 or CAC ≥ 75th percentile, it is reasonable to initiate statin therapy.
IIb B-R 8. In intermediate-risk adults who would benefit from more aggressive LDL-C lowering and in whom high-intensity statins are advisable, but not acceptable or tolerated, it may be reasonable to add a non-statin drug (ezetimibe or bile acid sequestrant) to a moderate-intensity statin.
IIb B-R 9. In patients at borderline risk, in risk discussion, the presence of risk-enhancing factors may justify initiation of moderate-intensity statin therapy.
Recommendations for Older Adults
COR   LOE   Recommendations
IIb B-R 1. In adults > 75 years of age with LDL-C of 70 to 189 mg/dL (1.7 to 4.8 mmol/L), initiating a moderate- intensity statin may be reasonable.
IIb B-R 2. In adults > 75 years of age, it may be reasonable to stop statin therapy when functional decline (physical or cognitive), multimorbidity, frailty or reduced life expectancy limit the potential benefits of statin therapy.
IIb B-R 3. In adults 76-80 years of age with LDL-C of 70 to 189 mg/dL (1.7 to 4.8 mmol/L), it may be reasonable to measure coronary artery calcium (CAC) to reclassify those with CAC = 0 to avoid statin therapy.
Recommendations for Patients with Diabetes Mellitus
COR   LOE   Recommendations
I A 1. In adults 40 to 75 years of age with diabetes, regardless of estimated 10-year ASCVD risk, moderate-intensity statin therapy is indicated.
IIa B-NR 2. In adults with diabetes who are 40 to 75 years of age and have LDL-C 70 to 189 mg/dL (1.7 to 4.8 mmol/L), it is reasonable to assess the 10-year risk of a first ASCVD event using the race and sex-specific Pooled Cohort Equations (PCE) to help stratify ASCVD risk.
IIa B-R 3. In adults with diabetes who have multiple ASCVD risk factors, it is reasonable to prescribe high-intensity statin therapy with the aim to reduce LDL-C by ≥50%.
IIa B-NR 4. In adults with diabetes older than 75 years of age who are already on statin therapy, it is reasonable to continue statin therapy.
IIb C-LD 5. In adults with diabetes and 10-year ASCVD risk ≥20%, it may be reasonable to add ezetimibe to maximum tolerated statin therapy to reduce LDL-C by ≥50%.
IIb C-LD 6. In adults with diabetes older than 75 years, after a patient discussion of potential benefits and risks, it may be reasonable to initiate statin therapy.
IIb C-LD 7. In adults 20 to 39 years of age with diabetes either of long duration (≥10 years of Type 2 diabetes, ≥20 years of Type 1), and/or albuminuria (≥30 mcg albumin/mg creatinine), eGFR <60 ml/min/m2, retinopathy, neuropathy, it may be reasonable to initiate statin therapy.
Recommendations for Primary Severe Hypercholesterolemia (LDL-C ≥ 190 mg/dL (≥ 4.9 mmol/L))
COR   LOE   Recommendations
I B-R 1. In patients 20 to 75 years of age with LDL-C ≥190 mg/dL (≥4.9 mmol/L), maximally-tolerated statin therapy is recommended.
IIa B-R 2. In patients 20 to 75 years of age with LDL-C ≥ 190 mg/dL (≥4.9 mmol/L), who achieve less than 50% reduction in LDL-C while receiving maximally-tolerated statin therapy, and/or have an LDL-C-≥100 mg/dL (≥2.6 mmol/L), ezetimibe therapy is reasonable.
IIb B-R 3. In patients 20 to 75 years of age with a baseline LDL-C ≥190 mg/dL (≥4.9 mmol/L), who achieve less than 50% reduction in LDL-C and have fasting triglycerides >300 mg/dL (>3.4 mmol/L) while taking maximally-tolerated statin and ezetimibe therapy, the addition of a bile acid sequestrant may be considered.
IIb B-R 4. In heterozygous familial hypercholesterolemia patients 30 to 75 years of age with LDL-C ≥100 mg/dL (≥2.6 mmol/L) while taking maximally-tolerated statin and ezetimibe therapy, the addition of a PCSK9 inhibitor may be considered.
IIb C-LD 5. In patients 40 to 75 years of age with a baseline LDL-C ≥220 mg/dL (≥5.7 mmol/L) who achieve on treatment LDL-C ≥130 mg/dL (≥3.4 mmol/L), while receiving maximally-tolerated statin and ezetimibe therapy, the addition of a PCSK9 inhibitor may be considered.
Value Statement: Uncertain Value (B-NR) 6. Among patients with familial hypercholesterolemia without evidence of clinical ASCVD taking maximally-tolerated statin and ezetimibe therapy, PCSK9 inhibitors provide uncertain value at 2018 US list prices.
Recommendations for Statin Therapy Use in Patients with ASCVD
COR   LOE   Recommendations
I A 1. In patients ≤75 years of age with clinical ASCVD*, high-intensity statin therapy should be initiated or continued with the aim of achieving a ≥50% reduction in LDL-C.
I A 2. In patients with clinical ASCVD in whom high-intensity statin therapy is contraindicated or who experience statin-associated side effects, moderate-intensity statin therapy should be initiated or continued with the aim of achieving a 30-49% reduction in LDL-C.
I B-NR 3. In patients with clinical ASCVD, who are judged to be very high-risk and considered for PCSK9 therapy, maximally tolerated LDL-C lowering therapy should include maximally tolerated statin therapy and ezetimibe
IIa A SR 4. In patients with clinical ASCVD, who are judged to be very high-risk and who are on maximally tolerated LDL-C lowering therapy with LDL-C ≥70 mg/dL (≥1.8 mmol/L) or non-HDL-C ≥100 mg/dL (≥2.6 mmol/L), it is reasonable to add a PCSK9 inhibitor following a clinician-patient discussion about the net benefit, safety, and cost.
IIa B-R 5. In patients with clinical ASCVD who are on maximally tolerated statin therapy and are judged to be at very high-risk, and have LDL-C ≥70 mg/dL (≥1.8 mmol/L), it is reasonable to add ezetimibe therapy.
Value Statement: Low Value (LOE: B-NR) 6. At mid-2018 list prices, PCSK9 inhibitors have a low-cost value (>$150,000 per QALY) compared to good cost value (<$50,000 per QALY) (Section 7 of the Guideline provides a full discussion of the dynamic interaction of different prices and clinical benefit)
IIa B-R 7. In patients with clinical ASCVD older than 75 years, it is reasonable to initiate moderate or high-intensity statin therapy after evaluating the potential for ASCVD risk-reduction, adverse effects, drug-drug interactions, frailty, and patient preferences.
IIa C-LD 8. In patients with clinical ASCVD older than 75 years of age who are tolerating high-intensity statin therapy, it is reasonable to continue high-intensity statin therapy after evaluating the potential for ASCVD risk-reduction, adverse effects, drug-drug interactions, frailty, and patient preferences.
IIb B-R 9. In patients with clinical ASCVD who are receiving maximally tolerated statin therapy and LDL-C remains ≥70 mg/dL (≥1.8 mmol/L), it may be reasonable to add ezetimibe.
IIb B-R 10. In patients with heart failure with reduced ejection fraction due to ischemic heart disease who have a reasonable life expectancy (3-5 years) and are not already on a statin due to ASCVD, clinicians may consider initiation of moderate-intensity statin therapy to reduce the occurrence of ASCVD events.

Primary Prevention of ASCVD - Summary

primary prevention

Intensities of Statin Therapy

High-, Moderate-, and Low-Intensity Statin Therapy

  High-Intensity Moderate-Intensity Low-Intensity
LDL-C
Lowering §
≥ 50% 30% to 49% < 30%
Primary
Statins
Atorvastatin (40†)-80 mg
Rosuvastatin 20 (40) mg
Atorvastatin 10 (20) mg
Rosuvastatin (5) 10 mg
Simvastatin 20-40 mg‡
Simvastatin 10 mg
Other
Statins
- Pravastatin 40 (80) mg
Lovastatin 40 (80) mg
Fluvastatin XL 80 mg
Fluvastatin 40 mg BID
Pitavastatin 1-4 mg
Pravastatin 10-20 mg
Lovastatin 20 mg
Fluvastatin 20-40 mg

Percent LDL-C reductions with the primary statin medications used in clinical practice (atorvastatin, rosuvastatin, simvastatin) were estimated using the median reduction in LDL-C from the VOYAGER database. Reductions in LDL-C for other statin medications (fluvastatin, lovastatin, pitavastatin, pravastatin) were identified according to FDA approved product labeling in adults with hyperlipidemia, primary hypercholesterolemia and mixed dyslipidemia.

Boldface type indicates specific statins and doses that were evaluated in RCTs, and the Cholesterol Treatment Trialists 2010 meta-analysis. All these RCTs demonstrated a reduction in major cardiovascular events.

Italic type indicates statins and doses that have been approved by the FDA but were not tested in the RCTs reviewed.

§ LDL-C lowering that should occur with the dosage listed below each intensity

‡ Although simvastatin 80 mg was evaluated in RCTs, initiation of simvastatin 80 mg or titration to 80 mg is not recommended by the FDA because of the increased risk of myopathy, including rhabdomyolysis

* Percent reductions are estimates from data across large populations. Individual responses to statin therapy varied in the RCTs and should be expected to vary in clinical practice.

† Evidence from 1 RCT only: down-titration if unable to tolerate atorvastatin 80 mg in the IDEAL (Incremental Decrease through Aggressive Lipid Lowering) study.

BID indicates twice daily; FDA, Food and Drug Administration; LDL-C, low-density lipoprotein cholesterol; and RCTs, randomized controlled trials.

Intensities of Statin Therapy

Low-Intensity

Daily dose lowers LDL-C, on average by approximately <30%

dose

Moderate-Intensity

Daily dose lowers LDL-C, on average by approximately 30% to <50%

dose

High-Intensity

Daily dose lowers LDL-C, on average by approximately ≥50%

dose

Statins and doses that are approved by the U.S. FDA but were not tested in the RCTs reviewed are listed in parentheses

* Evidence from 1 RCT (down-titration if unable to tolerate atorvastatin 80 mg)

** Initiation of or titration to simvastatin 80 mg is not recommended by the FDA due to increased risk of myopathy, including rhabdomyolysis

Recommendations to Monitor Response to LDL-C Lowering Therapy

Recommendations to Monitor Response to LDL-C Lowering Therapy
COR   LOE   Recommendations
I A Adherence to changes in lifestyle and effects of LDL-C lowering medication should be assessed by measurement of fasting lipids and appropriate safety indicators, 4 to 12 weeks after statin initiation or dose adjustment, and every 3-12 months thereafter based on need to assess adherence and/or safety.

Statin Safety Recommendations

Recommendations for Statin Safety and Statin Associated Side Effects
COR   LOE   Recommendations
I A 1. A clinician patient risk discussion is recommended before initiating statin therapy to review net clinical benefit, weighing the potential for ASCVD risk reduction against the potential for statin-associated side effects, statin-drug interactions and safety, yet emphasizing that side effects can be addressed successfully.
I A 2. In patients with statin-associated muscle symptoms, a thorough assessment of symptoms and an evaluation for non-statin causes and predisposing factors are recommended.
I B-R 3. In patients with indication for statin therapy identification of potential predisposing factors for statin associated side effects including new onset diabetes and statin-associated muscle symptoms is recommended prior to initiation of treatment.
I B-R 4. In patients with statin-associated side effects that are not severe, it is recommended to reassess and to rechallenge to achieve a maximal LDL-C lowering by modified dosing regimen, an alternate statin or in combination with non-statin therapy.
I B-R 5. In patients with increased diabetes risk or new onset diabetes, it is recommended to continue statin therapy with added emphasis on adherence, net clinical benefit, and the core principles of regular moderate-intensity physical activity, maintaining a healthy dietary pattern, and sustaining modest weight loss.
I C-LD 6. In patients treated with statins, it is recommended to measure creatine kinase levels in individuals with severe statin-associated muscle symptoms, objective muscle weakness, and to measure liver transaminases (aspartate aminotransferase, alanine aminotransferase) as well as total bilirubin and alkaline phosphatase (hepatic panel) if there are symptoms suggesting hepatotoxicity.
IIa B-R 7. In patients at increased ASCVD risk with chronic, stable liver disease (including non-alcoholic fatty liver disease) when appropriately indicated, it is reasonable to use statins after obtaining baseline measurements and determining a schedule of monitoring and safety checks.
IIa B-R 8. In patients at increased ASCVD risk with severe statin-associated muscle symptoms or recurrent statin-associated muscle symptoms despite appropriate statin rechallenge, it is reasonable to use RCT proven non-statin therapy that is likely to provide net clinical benefit.
III: No Benefit B-R 9. Coenzyme Q10 is not recommended for the routine use in patients treated with statins or for the treatment of statin-associated muscle symptoms.
III: No Benefit C-LD 10. In patients treated with statins, routine measurements of creatine kinase and transaminase levels are not useful.

Understanding My Cardiovascular Risk

The "2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk" provides clear recommendations for estimating cardiovascular disease risk. Risk assessments are extremely useful when it comes to reducing risk for cardiovascular disease because they help determine whether a patient is at high risk for cardiovascular disease, and if so, what can be done to address any cardiovascular risk factors a patient may have. Here are the highlights of the guideline:

  • Risk assessments are used to determine the likelihood of a patient developing cardiovascular disease, heart attack or stroke in the future. In general, patients at higher risk for cardiovascular disease require more intensive treatment to help prevent the development of cardiovascular disease.

  • Risk assessments are calculated using a number of factors including age, gender, race, cholesterol and blood pressure levels, diabetes and smoking status, and the use of blood pressure-lowering medications. Typically, these factors are used to estimate a patient's risk of developing cardiovascular disease in the next 10 years. For example, someone who is young with no risk factors for cardiovascular disease would have a very low 10-year risk for developing cardiovascular disease. However, someone who is older with risk factors like diabetes and high blood pressure will have a much higher risk of developing cardiovascular disease in the next 10 years.

  • If a preventive treatment plan is unclear based on the calculation of risk outlined above, care providers should take into account other factors such as family history and level of C-reactive protein. Taking this additional information into account should help inform a treatment plan to reduce a patient's 10-year risk of developing cardiovascular disease.

  • Calculating the 10-year risk for cardiovascular disease using traditional risk factors is recommended every 4-6 years in patients 20-79 years old who are free from cardiovascular disease. However, conducting a more detailed 10-year risk assessment every 4-6 years is reasonable in adults ages 40-79 who are free of cardiovascular disease. Assessing a patient's 30-year risk of developing cardiovascular disease can also be useful for patients 20-59 years of age who are free of cardiovascular disease and are not at high short-term risk for cardiovascular disease.

  • Risk estimations vary drastically by gender and race. Patients with the same traditional risk factors for cardiovascular disease such as high blood pressure can have a different 10-year risk for cardiovascular disease as a result of their sex and race.

  • After care providers and patients work together to conduct a risk assessment, it's important that they discuss the implications of their findings. Together, patients and their care providers should weigh the risks and benefits of various treatments and lifestyle changes to help reduce the risk of developing cardiovascular disease.

Source: www.cardiosmart.org

Diet and Physical Activity Recommendations

The "2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk" provides recommendations for heart-healthy lifestyle choices based on the latest research and evidence. The guidelines focus on two important lifestyle choices--diet and physical activity--which can have a drastic impact on cardiovascular health. Here's what every patient should know about the latest recommendations for reducing cardiovascular disease risk through diet and exercise.

Diet

  • Diet is a vital tool for lowering cholesterol and blood pressure levels, which are two major risk factors for cardiovascular disease.
  • Patients with high cholesterol and high blood pressure levels should eat plenty of vegetables, fruits and whole grains and incorporate low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils and nuts into their diet. They should also limit intake of sweets, sugar-sweetened beverages and red meats.
  • There are many helpful strategies for heart-healthy eating, including the DASH diet and the USDA's Choose My Plate.
  • Patients who need to lower their cholesterol should reduce saturated and trans fat intake. Ideally, only 5-6% of daily caloric intake should come from saturated fat.
  • Patients with high blood pressure should consume no more than 2,400 mg of sodium a day, ideally reducing sodium intake to 1,500 mg a day. However, even reducing sodium intake in one's current diet by 1,000 mg each day can help lower blood pressure.
  • It's important to adapt the recommendations above, keeping in mind calorie requirements, as well as, personal and cultural food preferences. Nutrition therapy for other conditions like diabetes should also be considered. Doing so helps create healthy eating patterns that are realistic and sustainable.

Physical Activity

  • Regular physical activity helps lower cholesterol and blood pressure, reducing the risk for cardiovascular disease.
  • In general, adults should engage in aerobic physical activity 3-4 times a week with each session lasting an average of 40 minutes.
  • Moderate (brisk walking or jogging) to vigorous (running or biking) physical activity is recommended to reduce cholesterol levels.

Source: www.cardiosmart.org

Weight Management Recommendations

The "2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults" was created to reflect the latest research to outline best practices when it comes to treating obesity--a condition that affects more than one-third of American adults. These guidelines help address questions like "What's the best way to lose weight?" and "When is bariatric surgery appropriate?". Here is what every patient should know about the treatment of overweight and obesity:

  • Definition of obesity: Obesity is a medical condition in which excess body fat has accumulated to the extent that it can have an adverse effect on one's health. Obesity can be diagnosed using body mass index (BMI), a measurement of height and weight, as well as waist circumference. Obesity is categorized as having a BMI of 30 or greater. Abdominal obesity is defined as having a waist circumference greater than 40 inches for a man or 35 inches for a woman.

  • Benefits of weight loss: Obesity increases the risk for serious conditions such as cardiovascular disease, diabetes and death, but losing just a little bit of weight can result in significant health benefits. For an adult who is obese, losing just 3-5% of body weight can improve blood pressure and cholesterol levels and reduce the risk for cardiovascular disease and diabetes. Ideally, care providers recommend 5-10% weight loss for obese adults, which can produce even greater health benefits.

  • Weight loss strategies: There is no single diet or weight loss program that works best for all patients. In general, reduced caloric intake and a comprehensive lifestyle intervention involving physical activity and behavior modification tailored according to a patient's preferences and health status is most successful for sustained weight loss. Further, weight loss interventions should include frequent visits with health care providers and last more than one year for sustained weight loss.

  • Bariatric Surgery: Bariatric surgery may be a good option for severely obese patients to reduce their risk of health complications and improve overall health. However, bariatric surgery should be reserved for only the highest risk patients until more evidence is available on this issue. Present guidelines advise that weight loss surgery is only recommended for patients with extreme obesity (BMI ≥40) or in patients that have a BMI ≥35 in addition to a chronic health condition.

Source: www.cardiosmart.org

Blood Cholesterol Management Recommendations

The American College of Cardiology (ACC) and the American Heart Association (AHA) recently developed new standards for treating blood cholesterol. These recommendations are based on a thorough and careful review of the very latest, highest quality clinical trial research. They help care providers deliver the best care possible. This page provides some of the highlights from the new practice guidelines. The ultimate goal of the new cholesterol practice guidelines is to reduce a person's risk of heart attack, stroke and death. For this reason, the focus is not just on measuring and treating cholesterol, but identifying whether someone already has or is at risk for atherosclerotic cardiovascular disease (ASCVD) and could benefit from treatment.

What is ASCVD?

Heart attack and stroke are usually caused by atherosclerotic cardiovascular disease (ASCVD). ASCVD develops because of a build-up of sticky cholesterol-rich plaque. Over time, this plaque can harden and narrow the arteries.

These practice guidelines outline the most effective treatments that lower blood cholesterol in those individuals most likely to benefit. Most importantly, they were selected as the best strategies to lower cholesterol to help reduce future heart attack or stroke risk. Share this information with your health care provider so that you can ask questions and work together to decide what is right for you.

Key Points

Based on the most up-to-date and complete look at available clinical trial results:

  • Health care providers should focus on identifying those people who are most likely to have a heart attack or stroke and make sure they are given effective treatment to reduce their risk.

  • Cholesterol should be considered along with other factors known to make a heart attack or stroke more likely.

  • Knowing your risk of heart attack and stroke can help you and your health care provider decide whether you may need to take a medication—most likely a statin—to lower that risk.

  • If a medication is needed, statins are recommended as the first choice to lower heart attack and stroke risk among certain higher-risk patients based on an overwhelming amount of evidence. For those unable to take a statin, there are other cholesterol-lowering drugs; however, there is less research to support their use.

Evaluating Your Risk

Your health care provider will first want to assess your risk of ASCVD (assuming you don't already have it). This information will help determine if you are at high enough risk of a heart attack or stroke to need treatment.

To do this, your care provider will 1) review your medical history and 2) gauge your overall risk for heart attack or stroke. He/she will likely want to know:

  • whether you have had a heart attack, stroke or blockages in the arteries of your heart, neck, or legs.

  • your risk factors. In addition to your total cholesterol, LDL cholesterol, and HDL (so-called "good") cholesterol, your health care provider will consider your age, if you have diabetes, and whether you smoke and/or have high blood pressure.

  • about your lifestyle habits, other medical conditions, any previous drug treatments, and if anyone in your family has high cholesterol or suffered a heart attack or stroke at an early age.

A lipid or blood cholesterol panel will be needed as part of this evaluation. This blood test measures the amount of fatty substances (called lipids) in your blood. You may have to fast (not eat for a period of time) before having your blood drawn.

If there is any question about your risk of ASCVD, or whether you might benefit from drug therapy, your care provider may make additional assessments or order additional tests. The results of these tests can help you and your health care team decide what might be the best treatment for you. These tests may include:

  • Lifetime risk estimates —how likely you are to have a heart attack and stroke during your lifetime

  • Coronary artery calcium (CAC) score —a test that shows the presence of plaque or fatty build-up in the heart artery walls

  • High-sensitivity C-Reactive Protein (CRP) —a blood test that measures the amount of CRP, a marker of inflammation or irritation in the body; higher levels have been associated with heart attack and stroke

  • Ankle-brachial index (ABI) —the ratio of the blood pressure in the ankle compared to blood pressure in the arm, which can predict peripheral artery disease (PAD)

If you have very high levels of low-density lipoprotein (LDL or "bad") cholesterol, your care provider may want to find out if you have a genetic or familial form of hypercholesterolemia. This condition can be passed on in families.

Your Treatment Plan

Before coming up with a specific treatment plan, your care provider will talk with you about options for lowering your blood cholesterol and reducing your personal risk of atherosclerotic disease. This will likely include a discussion about heart-healthy living and whether you might benefit from a cholesterol-lowering medication.

Heart-Healthy Lifestyle

Adopting a heart-healthy lifestyle continues to be the first and best way to lower your risk of problems. Doing so can also help control or prevent other risk factors (for example: high blood pressure or diabetes). Experts suggest:

  • Eating a diet rich in vegetables, fruits, and whole grains ; this also includes low-fat dairy products, poultry, fish, legumes, and nuts; it limits intake of sweets, sugar-sweetened beverages and red meats.

  • Getting regular exercise ; check with your health care provider about how often and how much is right for you.

  • Maintaining a healthy weight .

  • Not smoking or getting help quitting .

  • Staying on top of your health , risk factors and medical appointments. For some people, lifestyle changes alone may not be enough to prevent a heart attack or stroke. In these cases, taking a statin at the right dose will most likely be necessary.

Medications

There are two types of cholesterol-lowering medications: statins and non-statins.

Statin Therapy

There is a large body of evidence that shows the use of a statin provides the greatest benefit and fewest safety issues. In particular, specific groups of patients appear to benefit most from taking moderate or high-intensity statin therapy. Based on this information, your care provider will likely recommend a statin if you have:

  • ASCVD

  • Very high LDL cholesterol (190 mg/dL or higher)

  • Type 2 diabetes and are between 40 and 75 years of age

  • Above a certain likelihood of having a heart attack or stroke in the next 10 years (7.5% or higher) and are between 40 and 75 years of age

In certain cases, your care provider may still recommend a statin even if you don't fit into one of the groups above. He/she will consider your overall health and other factors to help decide if you are at enough risk to benefit from a statin. Based on the guidelines, these may include:

  • Family history of premature heart attack or stroke

  • Your lifetime risk of ASCVD

  • LDL-cholesterol ≥160 mg/dL

  • hs-CRP ≥2 mg/L

  • Results from other special testing (CAC scoring, ABI)

If you are on a statin, your care provider will need to find the dose that is right for you.

  • People who have had a heart attack, stroke or other types of ASCVD tend to benefit the most from taking the highest amount (dose) of statin therapy if they tolerate it. This may be more appropriate than taking multiple drugs to lower cholesterol.

  • A more moderate dose of statin may be appropriate for some people with ASCVD, such as those over 75 years or those that might have problems taking the highest dose of a statin (i.e., those with prior organ transplantation).

Sometimes more than one statin needs to be tried before finding the one that works best.

If you are 75 years or older and have not already had a heart attack, stroke or other types of ASCVD, your care provider will discuss whether a statin is right for you.

Other cholesterol-lowering medications

Not all patients will be able to take the optimum dose of statin. After attention to lifestyle changes and statin therapy, non-statin drugs may be considered if you have high-risk with known ASCVD, diabetes, or very high LDL cholesterol values (≥190 mg/dL) and:

  • Have side effects from statins that prevent you from getting to the optimal dose or are not able to take a statin at all.

  • Are limited from taking an optimal dose due to other drugs that you are taking, including:

    • Transplant drug regimens to prevent rejection

    • Multiple drugs to treat HIV

    • Some antibiotics like erythromycin and clarithromycin or certain oral anti-fungal drugs

As always, it's important to talk with your health care provider about which medication is right for you.

What About Having Goals of Treatment?

Although keeping LDL-cholesterol lower with an optimal dose of statin is supported strongly by clinical trials, getting to a specific goal level is not.

Staying on Top of Your Risk

  • Take steps to lower your risk factors for heart attack, stroke and other problems —Make healthy choices (eating a healthy diet, getting exercise, maintaining a healthy weight and not smoking). Drug therapy, if needed, can help control risk factors.

  • Report side effects —Muscle aches are commonly reported and may or may not be due to the statin. If you are having problems, your care provider needs to know to help manage any side effects and possibly switch you to a different statin.

  • Take your medications as directed .

  • Get blood cholesterol and other tests that are recommended by your health care team. These can help assess whether statin therapy—and the dose—is working for you.

Questions to Ask

  • What are my risk factors for heart attack and stroke? Am I on the best prevention program to minimize this risk?

  • Is my cholesterol high enough that it might be due to a genetic condition?

  • What lifestyle changes can I make to stay healthy and prevent problems?

  • Do I need to be on a statin?

  • How do I monitor how I am doing?

  • What should I do if I develop muscle aches or weakness after starting the statin?

  • What do I do if I have other symptoms after starting the statin?

Source: www.cardiosmart.org

Groups that Benefit from Statin Therapy Infographic

Groups that benifit from Statins

Common Cardiovascular Terms Alphabetical Glossary

    For additional cardiovascular terms visit www.cardiosmart.org

    Understanding Cardiovascular Risk

    10-Year ASCVD Risk

    • The 10-year calculated ASCVD risk is a quantitative estimation of absolute risk based upon data from representative population samples.
    • The 10-year risk estimate for "optimal risk factors" is represented by the following specific risk factor numbers for an individual of the same age, sex and race: Total cholesterol of ≤ 170 mg/dL, HDL-cholesterol of ≥ 50 mg/dL, untreated systolic blood pressure of ≤ 110 mm Hg, no diabetes history, and not a current smoker.
    • While the risk estimate is applied to individuals, it is based on group averages.
    • Just because two individuals have the same estimated risk does not mean that they will or will not have the same event of interest.
    • Example: If the 10-year ASCVD risk estimate is 10%, this indicates that among 100 patients with the entered risk factor profile, 10 would be expected to have a heart attack or stroke in the next 10 years.

    Lifetime ASCVD Risk

    • The lifetime calculated ASCVD risk represents a quantitative estimation of absolute risk for a 50 year old man or woman with the same risk profile.
    • This estimation of risk is based on the grouping of risk factor levels into 5 strata.
      • All risk factors are optimal*
      • ≥1 risk factors are not optimal†
      • ≥1 risk factors are elevated‡
      • 1 major risk factor§
      • ≥2 major risk factors§
    • The division of lifetime risk by these 5 strata leads to thresholds in the data with large apparent changes in lifetime risk estimates.
    • Example: An individual that has all optimal risk factors except for a systolic blood pressure of 119 mm Hg has a lifetime ASCVD risk of 5%. In contrast, a similar individual that has all optimal risk factors except for a systolic blood pressure of 120 mm Hg has a lifetime ASCVD risk of 36%. This substantial difference in lifetime risk is due to the fact that they are in different stratum.

    *Optimal risk levels for lifetime risk are represented by the simultaneous presence of all of the following: Untreated total cholesterol <180 mg/dL, untreated blood pressure <120/<80 mm Hg, no diabetes history, and not a current smoker

    †Nonoptimal risk levels for lifetime risk are represented by 1 or more of the following: Untreated total cholesterol of 180 to 199 mg/dL, untreated systolic blood pressure of 120 to 139 mm Hg or diastolic blood pressure of 80 to 89 mm Hg, and no diabetes history and not a current smoker

    ‡Elevated risk levels for lifetime risk are represented by 1 or more of the following: Untreated total cholesterol of 200 to 239 mg/dL, untreated systolic blood pressure of 140 to 159 mm Hg or diastolic blood pressure of 90 to 99 mm Hg, and no diabetes history and not a current smoker

    §Major risk levels for lifetime risk are represented by any of the following: Total cholesterol ≥240 mg/dL or treated, systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥100 mm Hg or treated, or diabetes, or current smoker

    Lifestyle Recommendations

    Diet recommendations

    Diet recommendations for LDL-C lowering

    1. Consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils and nuts; and limits intake of sweets, sugar-sweetened beverages, and red meats. (I A)
      • Adapt this dietary pattern to appropriate calorie requirements, personal and cultural food preferences, and nutrition therapy for other medical conditions (including diabetes mellitus).
      • Achieve this pattern by following plans such as the DASH dietary pattern, the USDA Food Pattern, or the AHA Diet.
    2. Aim for a dietary pattern that achieves 5-6% of calories from saturated fat. (I A)
    3. Reduce percent of calories from saturated fat. (I A)
    4. Reduce percent of calories from trans fat. (I A)

    Diet recommendations for blood pressure lowering

    1. Consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils and nuts; and limits intake of sweets, sugar-sweetened beverages, and red meats. (I A)
      • Adapt this dietary pattern to appropriate calorie requirements, personal and cultural food preferences, and nutrition therapy for other medical conditions (including diabetes mellitus).
      • Achieve this pattern by following plans such as the DASH dietary pattern, the USDA Food Pattern, or the AHA Diet.
    2. Lower sodium intake. (I A)
    3. Consume no more than 2400 mg of sodium per day. (I B)

    Weight Management Recommendations

    Diets for weight loss

    1. Prescribe a diet to achieve reduced calorie intake for obese or overweight individuals who would benefit from weight loss, as part of a comprehensive lifestyle intervention with 1 of the following (I A):
      • 1200-1500 kcal/day for women and 1500-1800 kcal/day for men.
      • 500-750 kcal/day energy deficit.
      • Use one of the evidence-based diets that restricts certain food types (e.g., high-carbohydrate foods, low-fiber foods, or high-fat foods) in order to create an energy deficit by reduced food intake.
    2. Prescribe a calorie-restricted diet for obese or overweight individuals who would benefit from weight loss, based on the patient's preferences and health status, and preferably refer to a nutrition professional for counseling. (I A)

    Lifestyle interventions and counseling for weight loss

    1. Advise participation in a comprehensive lifestyle program that assists participants in adhering to a lower calorie diet and increasing physical activity through the use of behavioral strategies. (I A)
    2. Prescribe on site, high-intensity (i.e., >14 sessions in 6 months) comprehensive weight loss interventions provided in individual or group sessions by a trained interventionist. (I A)
    3. Consider prescription of electronically delivered weight loss programs (including by telephone) that includes personalized feedback from a trained interventionist, recognizing that it may result in smaller weight loss than face-to-face interventions. (IIa A)
    4. Consider some commercial-based programs that provide comprehensive lifestyle interventions, provided there is peer-reviewed published evidence of their safety and efficacy. (IIa A)
    5. Consider a very low calorie diet (<800 kcal/day) only in limited circumstances and only when provided by trained practitioners in a medical care setting where medical monitoring and high intensity lifestyle intervention can be provided. (IIa A)
    6. Advise individuals who have lost weight to participate long term (>1 year) in a comprehensive weight loss maintenance program. (I A)
    7. Prescribe face-to-face or telephone-delivered weight loss maintenance programs that provide regular contact (> monthly) with a trained interventionist who helps participants engage in high levels of physical activity (i.e., 200-300 minutes/week), monitor body weight regularly (> weekly), and consume a reduced-calorie diet (need to lower body weight). (I A)

    Selection criteria for bariatric surgical treatment of obesity

    1. Advise adults with a BMI ≥40 kg/m2 or BMI ≥35 kg/m2 with obesity-related co-morbid conditions who are motivated to lose weight and who have not responded to behavioral treatment with or without pharmacotherapy with sufficient weight loss to achieve targeted health outcome goals that bariatric surgery may be an appropriate option to improve health and offer referral to an experienced bariatric surgeon for consultation and evaluation. (IIa A)

    Physical Activity Recommendations

    Physical activity recommendations for modifying lipids and blood pressure lowering

    1. Advise adults to engage in aerobic physical activity to reduce LDL-cholesterol, non-HDL-cholesterol, and blood pressure. (IIa A)
      • Frequency: 3-4 sessions a week
      • Intensity: Moderate to vigorous
      • Duration: 40 minutes on average

    Physical activity recommendations for secondary prevention*

    1. Aerobic exercise
      • Frequency: 3-5 days/week
      • Intensity: 50-80% of exercise capacity
      • Duration: 20-60 minutes
      • Modalities: Examples include walking, treadmill, cycling, rowing, stair climbing, and arm/leg ergometry
    2. Resistance exercise
      • Frequency: 2-3 days/week
      • Intensity: 10-15 repetitions/set to moderate fatigue
      • Duration: 1-3 sets of 8-10 upper and lower body exercises
      • Modalities: Examples include calisthenics, elastic bands, cuff/hand weights, dumbbells, free weights, wall pulleys, and weight machines
    *Balady GJ et al. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a Scientific Statement of the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation 2007;115:2675-2682

    Tobacco Cessation Recommendations

    5 R's for patients not ready to quit

    1. Relevance—Encourage the patient to indicate why quitting is personally relevant.
    2. Risks—Ask the patient to identify potential negative consequences of tobacco use.
    3. Rewards—Ask the patient to identify potential benefits of stopping tobacco use.
    4. Roadblocks—Ask the patient to identify barriers or impediments to quitting.
    5. Repetition—The motivational intervention should be repeated every time an unmotivated patient has an interaction with a clinician. Tobacco users who have failed in previous quit attempts should be told that most people make repeated quit attempts before they are successful.

    5 A's for patients that are ready to quit

    1. Ask—Systematically identify all tobacco users at every visit.
    2. Advise—Strongly urge all smokers to quit.
    3. Assess—Identify smokers willing to make a quit attempt.
    4. Assist—Aid the patient in quitting.
    5. Arrange—Schedule follow-up contact.

    Groups that Benefit from Statin Therapy

    1. Secondary Prevention: Clinical ASCVD

    Clinical ASCVD includes acute coronary syndromes, history of MI, stable or unstable angina, coronary or other arterial revascularization, stroke, TIA, or peripheral arterial disease presumed to be of atherosclerotic origin.

    High-intensity statin therapy should be initiated or continued as first-line therapy in women and men ≤75 years of age who have clinical ASCVD, unless contraindicated. (I A)

    In individuals with clinical ASCVD in whom high-intensity statin therapy would otherwise be used, when high-intensity statin therapy is contraindicated or when characteristics predisposing to statin-associated adverse effects are present, moderate-intensity statin should be used as the second option if tolerated. (I A)

    In individuals with clinical ASCVD >75 years of age, it is reasonable to evaluate the potential for ASCVD risk-reduction benefits and for adverse effects, drug-drug interactions and to consider patient preferences, when initiating a moderate- or high-intensity statin. It is reasonable to continue statin therapy in those who are tolerating it. (IIa B)

    2. Primary Prevention: LDL-C ≥190 mg/dL

    Individuals with LDL-C ≥190 mg/dL or triglycerides ≥500 mg/dL should be evaluated for secondary causes of hyperlipidemia. (I B)

    Adults ≥21 years of age with primary LDL-C ≥190 mg/dL should be treated with high-intensity statin therapy unless contraindicated. For individuals unable to tolerate high-intensity statin therapy, use the maximum tolerated statin intensity. (I B)

    For individuals ≥21 years of age with an untreated primary LDL-C ≥190 mg/dL, it is reasonable to intensify statin therapy to achieve at least a 50% LDL-C reduction. (IIa B)

    For individuals ≥21 years of age with an untreated primary LDL-C ≥190 mg/dL, after the maximum intensity of statin therapy has been achieved, addition of a nonstatin drug may be considered to further lower LDL-C. Evaluate the potential for ASCVD risk reduction benefits, adverse effects, drug-drug interactions, and consider patient preferences. (IIb C)

    3. Primary Prevention: Diabetes and aged 40 to 75 years with LDL-C between 70 - 189 mg/dL

    Moderate-intensity statin therapy should be initiated or continued for adults 40 to 75 years of age with diabetes mellitus. (I A)

    High-intensity statin therapy is reasonable for adults 40 to 75 years of age with diabetes mellitus with a ≥7.5% estimated 10-year ASCVD risk unless contraindicated. (IIa B)

    In adults with diabetes mellitus, who are <40 or >75 years of age, it is reasonable to evaluate the potential for ASCVD benefits and for adverse effects, for drug-drug interactions, and to consider patient preferences when deciding to initiate, continue, or intensify statin therapy. (IIa C)

    4. Primary Prevention: No diabetes and estimated 10-year ASCVD risk of ≥7.5% who are between 40 to 75 years of age with LDL-C between 70 - 189 mg/dL

    The Pooled Cohort Equations should be used to estimate 10-year ASCVD risk for individuals with LDL-C 70 to 189 mg/dL without clinical ASCVD to guide initiation of statin therapy for the primary prevention of ASCVD. (I B)

    Before initiating statin therapy for the primary prevention of ASCVD in adults with LDL-C 70 - 189 mg/dL without clinical ASCVD or diabetes it is reasonable for clinicians and patients to engage in a discussion which considers the potential for ASCVD risk reduction benefits and for adverse effects, for drug-drug interactions, and patient preferences for treatment. (IIa C)

    Adults 40 to 75 years of age with LDL-C 70 to 189 mg/dL, without clinical ASCVD or diabetes and an estimated 10-year ASCVD risk ≥7.5% should be treated with moderate- to high-intensity statin therapy. (I A)

    It is reasonable to offer treatment with a moderate-intensity statin to adults 40 to 75 years of age, with LDL-C 70 to 189 mg/dL, without clinical ASCVD or diabetes and an estimated 10-year ASCVD risk of 5% to <7.5%. (IIa B)

    In adults with LDL-C <190 mg/dL who are not otherwise identified in a statin benefit group, or for whom after quantitative risk assessment a risk-based treatment decision is uncertain, additional factors may be considered to inform treatment decision making. In these individuals, statin therapy for primary prevention may be considered after evaluating the potential for ASCVD risk reduction benefits, adverse effects, drug-drug interactions, and discussion of patient preferences. (IIb C)

    Additional Factors

    These factors may include:

    Statin benefit may be less clear in other groups; additional factors may be considered to inform treatment decision making.

    1. 5 to <7.5% 10-year ASCVD risk
    2. Primary LDL-C ≥160 mg/dL or other evidence of genetic hyperlipidemias
    3. Family history of premature ASCVD
    4. High sensitivity C-reactive protein ≥2 mg/L
    5. Coronary artery calcium score ≥300 Agatston units or ≥75th percentile for age, sex, and ethnicity
    6. Ankle-brachial index <0.9
    7. Lifetime risk of ASCVD

    General Populations Recommendation Summary

    Primary Prevention Recommendations for Adults 40-75 Years LDL 70-189 mg/dL (1.7 - 4.8 mmol/L)
    COR   LOE   Recommendations
    I A 1. In adults at intermediate-risk, statin therapy reduces risk of ASCVD and in the context of a risk discussion, if a decision is made for statin therapy, a moderate- intensity statin should be recommended.
    I A 2. In intermediate risk patients, LDL-C levels should be reduced by ≥ 30%, and for optimal ASCVD risk reduction, especially in high-risk patients, achieve LDL-C reductions of ≥ 50%.
    I B-NR 3. For the primary prevention of clinical ASCVD* in adults 40 to 75 years of age without diabetes and with LDL-C 70 to 189 mg/dL (1.7 to 4.8 mmol/L), the 10-year ASCVD risk of a first "hard" ASCVD event (fatal and non-fatal MI or stroke) should be estimated using the race and sex-specific Pooled Cohort Equations (PCE) and adults should be categorized as low risk (<5%), borderline risk (5 to <7.5%), intermediate-risk (≥7.5 to <20%), and high-risk (≥20%).
    I B-NR 4. Clinicians and patients should engage in a risk discussion that considers risk factors, adherence to healthy lifestyle, the potential for ASCVD risk-reduction benefits and the potential for adverse effects and drug–drug interactions, as well as patient preferences for an individualized treatment decision.
    IIa B-R 5. In intermediate-risk adults, risk-enhancing factors favor initiation or intensification of statin therapy.
    IIa B-NR 6. In intermediate-risk or selected borderline-risk adults, if the decision about statin usage remains uncertain, it is reasonable to use a coronary artery calcium (CAC) score in the decision to withhold, postpone or initiate statin therapy.
    IIa B-NR 7. In intermediate-risk adults or selected borderline-risk adults in whom a CAC score is measured for the purpose of making a treatment decision, AND
    • If CAC=0, it lowers risk therefore it is reasonable to withhold statin therapy and reassess CAC score in 5-10 years;
    • If CAC= 1 to 99, it is reasonable to initiate statin therapy for patients ≥ 55 years of age;
    • If CAC≥ 100 or CAC ≥ 75th percentile, it is reasonable to initiate statin therapy.
    IIb B-R 8. In intermediate-risk adults who would benefit from more aggressive LDL-C lowering and in whom high-intensity statins are advisable, but not acceptable or tolerated, it may be reasonable to add a non-statin drug (ezetimibe or bile acid sequestrant) to a moderate-intensity statin.
    IIb B-R 9. In patients at borderline risk, in risk discussion, the presence of risk-enhancing factors may justify initiation of moderate-intensity statin therapy.
    Recommenendations for Older Adults
    COR   LOE   Recommendations
    IIb B-R 1. In adults > 75 years of age with LDL-C of 70 to 189 mg/dL (1.7 to 4.8 mmol/L), initiating a moderate- intensity statin may be reasonable.
    IIb B-R 2. In adults > 75 years of age, it may be reasonable to stop statin therapy when functional decline (physical or cognitive), multimorbidity, frailty or reduced life expectancy limit the potential benefits of statin therapy.
    IIb B-R 3. In adults 76-80 years of age with LDL-C of 70 to 189 mg/dL (1.7 to 4.8 mmol/L), it may be reasonable to measure coronary artery calcium (CAC) to reclassify those with CAC = 0 to avoid statin therapy.
    Recommenendations for Patients with Diabetes Mellitus
    COR   LOE   Recommendations
    I A 1. In adults 40 to 75 years of age with diabetes, regardless of estimated 10-year ASCVD risk, moderate-intensity statin therapy is indicated.
    IIa A 2. In adults with diabetes who are 40 to 75 years of age and have LDL-C 70 to 189 mg/dL (1.7 to 4.8 mmol/L), it is reasonable to assess the 10-year risk of a first ASCVD event using the race and sex-specific Pooled Cohort Equations (PCE) to help stratify ASCVD risk.
    IIa B-NR 3. In adults with diabetes who have multiple ASCVD risk factors, it is reasonable to prescribe high-intensity statin therapy with the aim to reduce LDL-C by ≥50%.
    IIa B-NR 4. In adults with diabetes older than 75 years of age who are already on statin therapy, it is reasonable to continue statin therapy.
    IIb C-LD 5. In adults with diabetes and 10-year ASCVD risk ≥20%, it may be reasonable to add ezetimibe to maximum tolerated statin therapy to reduce LDL-C by ≥50%.
    IIb C-LD 6. In adults with diabetes older than 75 years, after a patient discussion of potential benefits and risks, it may be reasonable to initiate statin therapy.
    IIb C-LD 7. In adults 20 to 39 years of age with diabetes either of long duration (≥10 years of Type 2 diabetes, ≥20 years of Type 1), and/or albuminuria (≥30 mcg albumin/mg creatinine), eGFR <60 ml/min/m2, retinopathy, neuropathy, it may be reasonable to initiate statin therapy.
    Recommenendations for Primary Severe Hypercholesterolemia (LDL-C ≥ 190 mg/dL (≥ 4.9 mmol/L))
    COR   LOE   Recommendations
    I B-R 1. In patients 20 to 75 years of age with LDL-C ≥190 mg/dL (≥4.9 mmol/L), maximally-tolerated statin therapy is recommended.
    IIa B-R 2. In patients 20 to 75 years of age with LDL-C ≥ 190 mg/dL (≥4.9 mmol/L), who achieve less than 50% reduction in LDL-C while receiving maximally-tolerated statin therapy, and/or have an LDL-C-≥100 mg/dL (≥2.6 mmol/L), ezetimibe therapy is reasonable.
    IIb B-R 3. In patients 20 to 75 years of age with a baseline LDL-C ≥190 mg/dL (≥4.9 mmol/L), who achieve less than 50% reduction in LDL-C and have fasting triglycerides >300 mg/dL (>3.4 mmol/L) while taking maximally-tolerated statin and ezetimibe therapy, the addition of a bile acid sequestrant may be considered.
    IIb B-R 4. In heterozygous familial hypercholesterolemia patients 30 to 75 years of age with LDL-C ≥100 mg/dL (≥2.6 mmol/L) while taking maximally-tolerated statin and ezetimibe therapy, the addition of a PCSK9 inhibitor may be considered.
    IIb C-LD 5. In patients 40 to 75 years of age with a baseline LDL-C ≥220 mg/dL (≥5.7 mmol/L) who achieve on treatment LDL-C ≥130 mg/dL (≥3.4 mmol/L), while receiving maximally-tolerated statin and ezetimibe therapy, the addition of a PCSK9 inhibitor may be considered.
    Value Statement: Uncertain Value (B-NR) 6. Among patients with familial hypercholesterolemia without evidence of clinical ASCVD taking maximally-tolerated statin and ezetimibe therapy, PCSK9 inhibitors provide uncertain value at 2018 US list prices.
    Recommenendations for Statin Therapy Use in Patients with ASCVD
    COR   LOE   Recommendations
    I A 1. In patients ≤75 years of age with clinical ASCVD*, high-intensity statin therapy should be initiated or continued with the aim of achieving a ≥70% reduction in LDL-C.
    I A 2. In patients with clinical ASCVD in whom high-intensity statin therapy is contraindicated or who experience statin-associated side effects, moderate-intensity statin therapy should be initiated or continued with the aim of achieving a 30-49% reduction in LDL-C.
    IIa B-R 3. In patients with clinical ASCVD who are on maximally tolerated statin therapy and are judged to be at very high-risk, and have LDL-C ≥70 mg/dL (≥1.8 mmol/L), it is reasonable to add ezetimibe therapy.
    IIa A SR 4. In patients with clinical ASCVD, who are judged to be very high-risk and who are on maximally tolerated statin therapy and ezetimibe and have LDL-C ≥70 mg/dL (≥1.8 mmol/L) or non-HDL-C ≥100 mg/dL (≥2.6 mmol/L), it is reasonable to add a PCSK9 inhibitor following a clinician-patient discussion about the net benefit, safety, and cost.
    Value Statement: Low Value (LOE: B-NR) 5. Among patients with clinical ASCVD at high-risk and taking maximally tolerated statin and ezetimibe therapy, PCSK9 inhibitors provide low economic value at 2018 US list prices.
    IIa B-R 6. In patients with clinical ASCVD older than 75 years, it is reasonable to initiate moderate or high-intensity statin therapy after evaluating the potential for ASCVD risk-reduction, adverse effects, drug-drug interactions, frailty, and patient preferences.
    IIa C-LD 7. In patients with clinical ASCVD older than 75 years of age who are tolerating high-intensity statin therapy, it is reasonable to continue high-intensity statin therapy after evaluating the potential for ASCVD risk-reduction, adverse effects, drug-drug interactions, frailty, and patient preferences.
    IIb B-R 8. In patients with clinical ASCVD who are receiving maximally tolerated statin therapy and LDL-C remains ≥70 mg/dL (≥1.8 mmol/L), it may be reasonable to add ezetimibe.
    IIb B-R 9. In patients with heart failure with reduced ejection fraction due to ischemic heart disease who have a reasonable life expectancy (3-5 years) and are not already on a statin due to ASCVD, clinicians may consider initiation of moderate-intensity statin therapy to reduce the occurrence of ASCVD events.

    Recommendations for Initiation of Statin Therapy

    infographic on statin therapy

    This flow diagram is intended to serve as an easy reference guide summarizing recommendations for ASCVD risk assessment and treatment. Assessment of the potential for benefit and risk from statin therapy for ASCVD prevention provides the framework for clinical decision making incorporating patient preferences.

    * Percent reduction in LDL–C can be used as an indication of response and adherence to therapy, but is not in itself a treatment goal.

    The Pooled Cohort Equations can be used to estimate 10-year ASCVD risk in individuals with and without diabetes. The estimator within this application should be used to inform decision making in primary prevention patients not on a statin.

    Consider moderate-intensity statin as more appropriate in low-risk individuals.

    § For those in whom a risk assessment is uncertain, consider factors such as primary LDL–C ≥160 mg/dL or other evidence of genetic hyperlipidemias, family history of premature ASCVD with onset <55 years of age in a first-degree male relative or <65 years of age in a first-degree female relative, hs-CRP >2 mg/L, CAC score ≥300 Agatston units, or ≥75th percentile for age, sex, and ethnicity (for additional information, see http://www.mesa-nhlbi.org/CACReference.aspx), ABI <0.9, or lifetime risk of ASCVD. Additional factors that may aid in individual risk assessment may be identified in the future.

    || Potential ASCVD risk-reduction benefits. The absolute reduction in ASCVD events from moderate- or high-intensity statin therapy can be approximated by multiplying the estimated 10-year ASCVD risk by the anticipated relative risk reduction from the intensity of statin initiated (~30% for moderate-intensity statin or ~45% for high-intensity statin therapy). The net ASCVD risk reduction benefit is estimated from the number of potential ASCVD events prevented with a statin compared to the number of potential excess adverse events.

    Potential adverse effects. The excess risk of diabetes is the main consideration in ~0.1 excess cases per 100 individuals treated with a moderate-intensity statin for 1 year and ~0.3 excess cases per 100 individuals treated with a high-intensity statin for 1 year. In RCTs, both statin-treated and placebo-treated participants experienced the same rate of muscle symptoms. The actual rate of statin-related muscle symptoms in the clinical population is unclear. Muscle symptoms attributed to statin therapy should be evaluated (see Statin Safety Recommendations).

    ABI indicates ankle-brachial index; ASCVD, atherosclerotic cardiovascular disease; CAC, coronary artery calcium; hs-CRP, high-sensitivity C-reactive protein; LDL–C, low-density lipoprotein cholesterol; MI, myocardial infarction; RCT, randomized controlled trial.

    Intensities of Statin Therapy

    Low-Intensity

    Daily dose lowers LDL-C, on average by approximately <30%

    dose

    Moderate-Intensity

    Daily dose lowers LDL-C, on average by approximately 30% to <50%

    dose

    High-Intensity

    Daily dose lowers LDL-C, on average by approximately ≥50%

    dose

    Statins and doses that are approved by the U.S. FDA but were not tested in the RCTs reviewed are listed in parentheses

    * Evidence from 1 RCT (down-titration if unable to tolerate atorvastatin 80 mg)

    ** Initiation of or titration to simvastatin 80 mg is not recommended by the FDA due to increased risk of myopathy, including rhabdomyolysis

    Recommendations to Monitor Response to Statin Therapy

    infographic on statin therapy

    *Fasting lipid panel preferred. In a nonfasting individual, a non–HDL–C ≥ 220 mg/dL may indicate genetic hypercholesterolemia that requires further evaluation or a secondary etiology. If nonfasting triglycerides are ≥ 500 mg/dL, a fasting lipid panel is required.

    In those already on a statin, in whom baseline LDL–C is unknown, an LDL–C <100 mg/dL was observed in most individuals receiving high-intensity statin therapy in RCTs.

    Refer to Statin Safety Recommendations

    Statin Safety Recommendations

    Statin Selection

    To maximize the safety of statins, selection of the appropriate statin and dose in men and nonpregnant/nonnursing women should be based on patient characteristics, level of ASCVD risk, and potential for adverse effects.

    Moderate-intensity statin therapy should be used in individuals in whom high-intensity statin therapy would otherwise be recommended when characteristics predisposing them to statin associated adverse effects are present.

    Characteristics predisposing individuals to statin adverse effects include, but are not limited to: (I B)

    • Multiple or serious comorbidities, including impaired renal or hepatic function.
    • History of previous statin intolerance or muscle disorders.
    • Unexplained ALT elevations >3 times ULN.
    • Patient characteristics or concomitant use of drugs affecting statin metabolism.
    • >75 years of age.

    Additional characteristics that may modify the decision to use higher statin intensities may include, but are not limited to:

    • History of hemorrhagic stroke.
    • Asian ancestry.

    Statin Dosage

    • Decreasing the statin dose may be considered when 2 consecutive values of LDL-C levels are <40 mg/dL. (IIb C)
    • It may be harmful to initiate simvastatin at 80 mg daily or increase the dose of simvastatin to 80 mg daily. (III A)

    Creatine Kinase (CK)

    • CK should not be routinely measured in individuals receiving statin therapy. (III A)
    • Baseline measurement of CK is reasonable for individuals believed to be at increased risk for adverse muscle events based on a personal or family history of statin intolerance or muscle disease, clinical presentation, or concomitant drug therapy that might increase the risk for myopathy. (IIa C)
    • During statin therapy, it is reasonable to measure CK in individuals with muscle symptoms, including pain, tenderness, stiffness, cramping, weakness, or generalized fatigue. (II C)

    Muscle Symptoms

    It is reasonable to evaluate and treat muscle symptoms, including pain, tenderness, stiffness, cramping, weakness, or fatigue, in statin-treated patients according to the following management algorithm: (IIa B)

    • To avoid unnecessary discontinuation of statins, obtain a history of prior or current muscle symptoms to establish a baseline before initiating statin therapy.
    • If unexplained severe muscle symptoms or fatigue develop during statin therapy, promptly discontinue the statin and address the possibility of rhabdomyolysis by evaluating CK, creatinine, and a urinalysis for myoglobinuria.
    • If mild to moderate muscle symptoms develop during statin therapy:
      • Discontinue the statin until the symptoms can be evaluated.
      • Evaluate the patient for other conditions that might increase the risk for muscle symptoms (e.g., hypothyroidism, reduced renal or hepatic function, rheumatologic disorders such as polymyalgia rheumatica, steroid myopathy, vitamin D deficiency, or primary muscle diseases).
      • If muscle symptoms resolve, and if no contraindication exists, give the patient the original or a lower dose of the same statin to establish a causal relationship between the muscle symptoms and statin therapy.
      • If a causal relationship exists, discontinue the original statin. Once muscle symptoms resolve, use a low dose of a different statin.
      • Once a low dose of a statin is tolerated, gradually increase the dose as tolerated.
      • If, after 2 months without statin treatment, muscle symptoms or elevated CK levels do not resolve completely, consider other causes of muscle symptoms listed above.
      • If persistent muscle symptoms are determined to arise from a condition unrelated to statin therapy, or if the predisposing condition has been treated, resume statin therapy at the original dose.

    Hepatic Function

    • Baseline measurement of hepatic transaminase levels (ALT) should be performed before initiating statin therapy. (I B)
    • During statin therapy, it is reasonable to measure hepatic function if symptoms suggesting hepatotoxicity arise (e.g., unusual fatigue or weakness, loss of appetite, abdominal pain, dark colored urine or yellowing of the skin or sclera). (IIa C)

    Diabetes

    Individuals receiving statin therapy should be evaluated for new-onset diabetes mellitus according to the current diabetes screening guidelines. Those who develop diabetes mellitus during statin therapy should be encouraged to adhere to a heart healthy dietary pattern, engage in physical activity, achieve and maintain a healthy body weight, cease tobacco use, and continue statin therapy to reduce their risk of ASCVD events. (I B)

    Age and Drug Regimen Consideration

    For individuals taking any dose of statins, it is reasonable to use caution in individuals >75 years of age, as well as in individuals that are taking concomitant medications that alter drug metabolism, taking multiple drugs, or taking drugs for conditions that require complex medication regimens (e.g., those who have undergone solid organ transplantation or are receiving treatment for HIV). A review of the manufacturer's prescribing information may be useful before initiating any cholesterol-lowering drug. (IIa C)

    Cognitive Impairment

    For individuals presenting with a confusional state or memory impairment while on statin therapy, it may be reasonable to evaluate the patient for nonstatin causes, such as exposure to other drugs, as well as for systemic and neuropsychiatric causes, in addition to the possibility of adverse effects associated with statin drug therapy. (IIb C)

    Understanding My Cardiovascular Risk

    The "2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk" provides clear recommendations for estimating cardiovascular disease risk. Risk assessments are extremely useful when it comes to reducing risk for cardiovascular disease because they help determine whether a patient is at high risk for cardiovascular disease, and if so, what can be done to address any cardiovascular risk factors a patient may have. Here are the highlights of the guideline:

    • Risk assessments are used to determine the likelihood of a patient developing cardiovascular disease, heart attack or stroke in the future. In general, patients at higher risk for cardiovascular disease require more intensive treatment to help prevent the development of cardiovascular disease.

    • Risk assessments are calculated using a number of factors including age, gender, race, cholesterol and blood pressure levels, diabetes and smoking status, and the use of blood pressure-lowering medications. Typically, these factors are used to estimate a patient's risk of developing cardiovascular disease in the next 10 years. For example, someone who is young with no risk factors for cardiovascular disease would have a very low 10-year risk for developing cardiovascular disease. However, someone who is older with risk factors like diabetes and high blood pressure will have a much higher risk of developing cardiovascular disease in the next 10 years.

    • If a preventive treatment plan is unclear based on the calculation of risk outlined above, care providers should take into account other factors such as family history and level of C-reactive protein. Taking this additional information into account should help inform a treatment plan to reduce a patient's 10-year risk of developing cardiovascular disease.

    • Calculating the 10-year risk for cardiovascular disease using traditional risk factors is recommended every 4-6 years in patients 20-79 years old who are free from cardiovascular disease. However, conducting a more detailed 10-year risk assessment every 4-6 years is reasonable in adults ages 40-79 who are free of cardiovascular disease. Assessing a patient's 30-year risk of developing cardiovascular disease can also be useful for patients 20-59 years of age who are free of cardiovascular disease and are not at high short-term risk for cardiovascular disease.

    • Risk estimations vary drastically by gender and race. Patients with the same traditional risk factors for cardiovascular disease such as high blood pressure can have a different 10-year risk for cardiovascular disease as a result of their sex and race.

    • After care providers and patients work together to conduct a risk assessment, it's important that they discuss the implications of their findings. Together, patients and their care providers should weigh the risks and benefits of various treatments and lifestyle changes to help reduce the risk of developing cardiovascular disease.

    Source: www.cardiosmart.org

    Diet and Physical Activity Recommendations

    The "2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk" provides recommendations for heart-healthy lifestyle choices based on the latest research and evidence. The guidelines focus on two important lifestyle choices--diet and physical activity--which can have a drastic impact on cardiovascular health. Here's what every patient should know about the latest recommendations for reducing cardiovascular disease risk through diet and exercise.

    Diet

    • Diet is a vital tool for lowering cholesterol and blood pressure levels, which are two major risk factors for cardiovascular disease.
    • Patients with high cholesterol and high blood pressure levels should eat plenty of vegetables, fruits and whole grains and incorporate low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils and nuts into their diet. They should also limit intake of sweets, sugar-sweetened beverages and red meats.
    • There are many helpful strategies for heart-healthy eating, including the DASH diet and the USDA's Choose My Plate.
    • Patients who need to lower their cholesterol should reduce saturated and trans fat intake. Ideally, only 5-6% of daily caloric intake should come from saturated fat.
    • Patients with high blood pressure should consume no more than 2,400 mg of sodium a day, ideally reducing sodium intake to 1,500 mg a day. However, even reducing sodium intake in one's current diet by 1,000 mg each day can help lower blood pressure.
    • It's important to adapt the recommendations above, keeping in mind calorie requirements, as well as, personal and cultural food preferences. Nutrition therapy for other conditions like diabetes should also be considered. Doing so helps create healthy eating patterns that are realistic and sustainable.

    Physical Activity

    • Regular physical activity helps lower cholesterol and blood pressure, reducing the risk for cardiovascular disease.
    • In general, adults should engage in aerobic physical activity 3-4 times a week with each session lasting an average of 40 minutes.
    • Moderate (brisk walking or jogging) to vigorous (running or biking) physical activity is recommended to reduce cholesterol levels.

    Source: www.cardiosmart.org

    Weight Management Recommendations

    The "2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults" was created to reflect the latest research to outline best practices when it comes to treating obesity--a condition that affects more than one-third of American adults. These guidelines help address questions like "What's the best way to lose weight?" and "When is bariatric surgery appropriate?". Here is what every patient should know about the treatment of overweight and obesity:

    • Definition of obesity: Obesity is a medical condition in which excess body fat has accumulated to the extent that it can have an adverse effect on one's health. Obesity can be diagnosed using body mass index (BMI), a measurement of height and weight, as well as waist circumference. Obesity is categorized as having a BMI of 30 or greater. Abdominal obesity is defined as having a waist circumference greater than 40 inches for a man or 35 inches for a woman.

    • Benefits of weight loss: Obesity increases the risk for serious conditions such as cardiovascular disease, diabetes and death, but losing just a little bit of weight can result in significant health benefits. For an adult who is obese, losing just 3-5% of body weight can improve blood pressure and cholesterol levels and reduce the risk for cardiovascular disease and diabetes. Ideally, care providers recommend 5-10% weight loss for obese adults, which can produce even greater health benefits.

    • Weight loss strategies: There is no single diet or weight loss program that works best for all patients. In general, reduced caloric intake and a comprehensive lifestyle intervention involving physical activity and behavior modification tailored according to a patient's preferences and health status is most successful for sustained weight loss. Further, weight loss interventions should include frequent visits with health care providers and last more than one year for sustained weight loss.

    • Bariatric Surgery: Bariatric surgery may be a good option for severely obese patients to reduce their risk of health complications and improve overall health. However, bariatric surgery should be reserved for only the highest risk patients until more evidence is available on this issue. Present guidelines advise that weight loss surgery is only recommended for patients with extreme obesity (BMI ≥40) or in patients that have a BMI ≥35 in addition to a chronic health condition.

    Source: www.cardiosmart.org

    Blood Cholesterol Management Recommendations

    The American College of Cardiology (ACC) and the American Heart Association (AHA) recently developed new standards for treating blood cholesterol. These recommendations are based on a thorough and careful review of the very latest, highest quality clinical trial research. They help care providers deliver the best care possible. This page provides some of the highlights from the new practice guidelines. The ultimate goal of the new cholesterol practice guidelines is to reduce a person's risk of heart attack, stroke and death. For this reason, the focus is not just on measuring and treating cholesterol, but identifying whether someone already has or is at risk for atherosclerotic cardiovascular disease (ASCVD) and could benefit from treatment.

    What is ASCVD?

    Heart attack and stroke are usually caused by atherosclerotic cardiovascular disease (ASCVD). ASCVD develops because of a build-up of sticky cholesterol-rich plaque. Over time, this plaque can harden and narrow the arteries.

    These practice guidelines outline the most effective treatments that lower blood cholesterol in those individuals most likely to benefit. Most importantly, they were selected as the best strategies to lower cholesterol to help reduce future heart attack or stroke risk. Share this information with your health care provider so that you can ask questions and work together to decide what is right for you.

    Key Points

    Based on the most up-to-date and complete look at available clinical trial results:

    • Health care providers should focus on identifying those people who are most likely to have a heart attack or stroke and make sure they are given effective treatment to reduce their risk.

    • Cholesterol should be considered along with other factors known to make a heart attack or stroke more likely.

    • Knowing your risk of heart attack and stroke can help you and your health care provider decide whether you may need to take a medication—most likely a statin—to lower that risk.

    • If a medication is needed, statins are recommended as the first choice to lower heart attack and stroke risk among certain higher-risk patients based on an overwhelming amount of evidence. For those unable to take a statin, there are other cholesterol-lowering drugs; however, there is less research to support their use.

    Evaluating Your Risk

    Your health care provider will first want to assess your risk of ASCVD (assuming you don't already have it). This information will help determine if you are at high enough risk of a heart attack or stroke to need treatment.

    To do this, your care provider will 1) review your medical history and 2) gauge your overall risk for heart attack or stroke. He/she will likely want to know:

    • whether you have had a heart attack, stroke or blockages in the arteries of your heart, neck, or legs.

    • your risk factors. In addition to your total cholesterol, LDL cholesterol, and HDL (so-called "good") cholesterol, your health care provider will consider your age, if you have diabetes, and whether you smoke and/or have high blood pressure.

    • about your lifestyle habits, other medical conditions, any previous drug treatments, and if anyone in your family has high cholesterol or suffered a heart attack or stroke at an early age.

    A lipid or blood cholesterol panel will be needed as part of this evaluation. This blood test measures the amount of fatty substances (called lipids) in your blood. You may have to fast (not eat for a period of time) before having your blood drawn.

    If there is any question about your risk of ASCVD, or whether you might benefit from drug therapy, your care provider may make additional assessments or order additional tests. The results of these tests can help you and your health care team decide what might be the best treatment for you. These tests may include:

    • Lifetime risk estimates —how likely you are to have a heart attack and stroke during your lifetime

    • Coronary artery calcium (CAC) score —a test that shows the presence of plaque or fatty build-up in the heart artery walls

    • High-sensitivity C-Reactive Protein (CRP) —a blood test that measures the amount of CRP, a marker of inflammation or irritation in the body; higher levels have been associated with heart attack and stroke

    • Ankle-brachial index (ABI) —the ratio of the blood pressure in the ankle compared to blood pressure in the arm, which can predict peripheral artery disease (PAD)

    If you have very high levels of low-density lipoprotein (LDL or "bad") cholesterol, your care provider may want to find out if you have a genetic or familial form of hypercholesterolemia. This condition can be passed on in families.

    Your Treatment Plan

    Before coming up with a specific treatment plan, your care provider will talk with you about options for lowering your blood cholesterol and reducing your personal risk of atherosclerotic disease. This will likely include a discussion about heart-healthy living and whether you might benefit from a cholesterol-lowering medication.

    Heart-Healthy Lifestyle

    Adopting a heart-healthy lifestyle continues to be the first and best way to lower your risk of problems. Doing so can also help control or prevent other risk factors (for example: high blood pressure or diabetes). Experts suggest:

    • Eating a diet rich in vegetables, fruits, and whole grains ; this also includes low-fat dairy products, poultry, fish, legumes, and nuts; it limits intake of sweets, sugar-sweetened beverages and red meats.

    • Getting regular exercise ; check with your health care provider about how often and how much is right for you.

    • Maintaining a healthy weight .

    • Not smoking or getting help quitting .

    • Staying on top of your health , risk factors and medical appointments. For some people, lifestyle changes alone may not be enough to prevent a heart attack or stroke. In these cases, taking a statin at the right dose will most likely be necessary.

    Medications

    There are two types of cholesterol-lowering medications: statins and non-statins.

    Statin Therapy

    There is a large body of evidence that shows the use of a statin provides the greatest benefit and fewest safety issues. In particular, specific groups of patients appear to benefit most from taking moderate or high-intensity statin therapy. Based on this information, your care provider will likely recommend a statin if you have:

    • ASCVD

    • Very high LDL cholesterol (190 mg/dL or higher)

    • Type 2 diabetes and are between 40 and 75 years of age

    • Above a certain likelihood of having a heart attack or stroke in the next 10 years (7.5% or higher) and are between 40 and 75 years of age

    In certain cases, your care provider may still recommend a statin even if you don't fit into one of the groups above. He/she will consider your overall health and other factors to help decide if you are at enough risk to benefit from a statin. Based on the guidelines, these may include:

    • Family history of premature heart attack or stroke

    • Your lifetime risk of ASCVD

    • LDL-cholesterol ≥160 mg/dL

    • hs-CRP ≥2 mg/L

    • Results from other special testing (CAC scoring, ABI)

    If you are on a statin, your care provider will need to find the dose that is right for you.

    • People who have had a heart attack, stroke or other types of ASCVD tend to benefit the most from taking the highest amount (dose) of statin therapy if they tolerate it. This may be more appropriate than taking multiple drugs to lower cholesterol.

    • A more moderate dose of statin may be appropriate for some people with ASCVD, such as those over 75 years or those that might have problems taking the highest dose of a statin (i.e., those with prior organ transplantation).

    Sometimes more than one statin needs to be tried before finding the one that works best.

    If you are 75 years or older and have not already had a heart attack, stroke or other types of ASCVD, your care provider will discuss whether a statin is right for you.

    Other cholesterol-lowering medications

    Not all patients will be able to take the optimum dose of statin. After attention to lifestyle changes and statin therapy, non-statin drugs may be considered if you have high-risk with known ASCVD, diabetes, or very high LDL cholesterol values (≥190 mg/dL) and:

    • Have side effects from statins that prevent you from getting to the optimal dose or are not able to take a statin at all.

    • Are limited from taking an optimal dose due to other drugs that you are taking, including:

      • Transplant drug regimens to prevent rejection

      • Multiple drugs to treat HIV

      • Some antibiotics like erythromycin and clarithromycin or certain oral anti-fungal drugs

    As always, it's important to talk with your health care provider about which medication is right for you.

    What About Having Goals of Treatment?

    Although keeping LDL-cholesterol lower with an optimal dose of statin is supported strongly by clinical trials, getting to a specific goal level is not.

    Staying on Top of Your Risk

    • Take steps to lower your risk factors for heart attack, stroke and other problems —Make healthy choices (eating a healthy diet, getting exercise, maintaining a healthy weight and not smoking). Drug therapy, if needed, can help control risk factors.

    • Report side effects —Muscle aches are commonly reported and may or may not be due to the statin. If you are having problems, your care provider needs to know to help manage any side effects and possibly switch you to a different statin.

    • Take your medications as directed .

    • Get blood cholesterol and other tests that are recommended by your health care team. These can help assess whether statin therapy—and the dose—is working for you.

    Questions to Ask

    • What are my risk factors for heart attack and stroke? Am I on the best prevention program to minimize this risk?

    • Is my cholesterol high enough that it might be due to a genetic condition?

    • What lifestyle changes can I make to stay healthy and prevent problems?

    • Do I need to be on a statin?

    • How do I monitor how I am doing?

    • What should I do if I develop muscle aches or weakness after starting the statin?

    • What do I do if I have other symptoms after starting the statin?

    Source: www.cardiosmart.org

    Groups that Benefit from Statin Therapy Infographic

    Groups that benifit from Statins

    Common Cardiovascular Terms Alphabetical Glossary

      For additional cardiovascular terms visit www.cardiosmart.org

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