ACC AHA guideline on the primary prevention of hypercholestrolemia

Template:Hypercholesterolemia Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Primary Prevention in Adult ≥21 Years With LDL–C ≥190 mg/dL

• Adults ≥21 years of age with primary, severe elevations of LDL–C (≥190 mg/dL) have a high lifetime risk for ASCVD events and require even more substantial reductions in their LDL–C levels and intensive management of other risk factors to reduce their ASCVD event. It is reasonable to use high-intensity statin therapy to achieve at least a 50% reduction. In addition to a maximally tolerated dose of statin, nonstatin cholesterol-lowering medications are often needed to lower LDL–C to acceptable levels in these individuals.

• Because the hypercholesterolemia in these high-risk individuals is often genetically determined, family screening is especially important in this group to identify additional family members who would benefit from assessment and early treatment.

• Secondary causes of severe elevations of LDL–C ≥190 mg/dL and triglycerides ≥500 mg/dL often contribute to the magnitude of the hyperlipidemia and should be evaluated and treated appropriately. The most frequently encountered secondary conditions were excessive alcohol intake, uncontrolled diabetes mellitus and overt albuminuria.

Secondary Cause	Elevated LDL–C	Elevated Triglycerides
Diet	Saturated or trans fats, weight gain, anorexia	Weight gain, very low-fat diets, high intake of refined carbohydrates, excessive alcohol intake
Drugs	Diuretics, cyclosporine, glucocorticoids, amiodarone	Oral estrogens, glucocorticoids, bile acid sequestrants, protease inhibitors, retinoic acid, anabolic steroids, sirolimus, raloxifene, tamoxifen, beta blockers (not carvedilol), thiazides
Diseases	Biliary obstruction, nephrotic syndrome	Nephrotic syndrome, chronic renal failure, lipodystrophies
Disorders and altered states of metabolism	Hypothyroidism, obesity, pregnancy*	Diabetes (poorly controlled), hypothyroidism, obesity; pregnancy*

* Cholesterol and triglycerides rise progressively throughout pregnancy (81); treatment with statins, niacin, and ezetimibe are contraindicated during pregnancy and lactation.

Primary Prevention in Individuals With Diabetes

• The use of moderate-intensity statin therapy should be considered in individuals with diabetes that are 40 to 75 years of age since they are at substantially increased lifetime risk for ASCVD events and death. Moreover, individuals with diabetes experience greater morbidity and worse survival following the onset of clinical ASCVD.

• In persons with diabetes <40 or >75 years of age, statin therapy should be individualized based on considerations of ASCVD risk reduction benefits, the potential for adverse effects and drug-drug interactions, and patient preferences.

Primary Prevention in Individuals Without Diabetes and With LDL–C 70 to 189 mg/dL

• In individuals 40 to 75 years of age with LDL–C 70 to 189 mg/dL who are without clinical ASCVD or diabetes, initiation of statin therapy based on estimated 10-year ASCVD risk is recommended, regardless of sex, race or ethnicity.

• In individuals 40 to 75 years of age, who are not already candidates for statin therapy based on the presence of clinical ASCVD, diabetes, or LDL–C ≥190 mg/dL, it is recommended to receive statin therapy if they have a ≥7.5% estimated 10-year risk for ASCVD and LDL–C 70 to 189 mg/dL.

• Before initiating statin therapy, the clinician and patient discussion should include consideration of the potential for ASCVD risk reduction benefits, adverse effects, and drug-drug interactions. Additional factors may also be considered to inform treatment decision making in selected individuals. Factors that may contribute to assessment of ASCVD risk include 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, high- sensitivity C-reactive protein >2 mg/L, coronary artery calcium score ≥300 Agatston units or ≥75 percentile for age, sex, and ethnicity, ankle brachial index <0.9, or elevated lifetime risk of ASCVD.

Initiating and Management of Statin Therapy in Individuals Without Clinical ASCVD

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

References

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