Clinical Question

What do cardiologists recommend for the management of hyperlipidemia?

Bottom Line

These updated guidelines, made without any input from primary care physicians who manage most patients with hyperlipidemia, are more complex than the 2013 guidelines and will likely lead to even more recommendations for statins, ezetimibe (Zetia), and PSK9 inhibitors. Rather than a “fire and forget” strategy involving a risk-based prescription of a moderate- or high-intensity statin, we are supposed to go back to monitoring low-density lipoprotein (LDL) levels and targeting a percentage reduction in LDL cholesterol—and in very high-risk patients targeting an LDL level of less than 70 mg per dL (1.81 mmol per L). (Level of Evidence = 1a−)

Synopsis

This is an update to the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines, which were the first to base treatment decisions primarily on the 10-year risk of an atherosclerotic cardiovascular disease (ASCVD) event rather than on specific LDL targets. This guideline reemphasizes regularly measuring lipids and a return to an LDL target for assessing effectiveness and deciding when to prescribe one of the new and pricey PSK9 inhibitors ($14,000 to $15,000 per year at http://www.goodrx.com, December 1, 2018). Statins are divided into high intensity (atorvastatin [Lipitor], 40 to 80 mg; rosuvastatin [Crestor], 20 to 40 mg), moderate-intensity (atorvastatin, 10 to 20 mg; simvastatin [Zocor], 20 to 40 mg; rosuvastatin, 5 to 10 mg), and low-intensity (simvastatin, 10 mg) groups. For primary prevention in people 20 to 39 years of age, the guidelines recommend an assessment of the lifetime risk of ASCVD as a way to frighten patients into compliance with lifestyle changes. For people 20 to 39 years of age with LDL levels greater than 160 mg per dL (4.14 mmol per L) or a family history of premature ASCVD, a statin is recommended. For patients 40 years and older, a high-intensity statin is recommended for an LDL level greater than 190 mg per dL (4.92 mmol per L) and a moderate- or high-intensity statin (depending on other risk factors) for those with diabetes mellitus.

For all other patients, the Pooled Cohort Equations are used to place patients into one of four risk groups; the old guideline had only three. If the 10-year risk of an ASCVD event is less than 5%, no statin is recommended. If the 10-year risk is 5% to 7.5%, consider a moderate-intensity statin if there is also a “risk enhancer,” such as LDL level greater than 160 mg per dL, family history of premature ASCVD, chronic kidney disease, metabolic syndrome, South Asian ancestry, preeclampsia, HIV, rheumatoid arthritis, or psoriasis. For persons with a 7.5% to 20% risk, they recommend a moderate-intensity statin for most patients to target a 30% to 49% reduction in LDL cholesterol. Finally, if the risk is greater than 20%, a statin to target a 50% or more reduction in LDL cholesterol is recommended. For prevention in persons with known vascular disease, a new category of very high risk is described. It is defined as two or more of the following major events: acute coronary syndrome in the past 12 months, previous myocardial infarction, previous ischemic stroke, or symptomatic peripheral artery disease. A patient is also very high risk if he or she has one of those major ASCVD events and multiple high-risk conditions, such as familial hypercholesterolemia, age of at least 65 years, hypertension, diabetes, chronic kidney disease, tobacco use, heart failure, or LDL level greater than 100 mg per dL (2.59 mmol per L) despite maximal statin plus ezetimibe therapy. Patients in this category should be taking a high-intensity statin, adding ezetimibe if necessary, to target an LDL level of 70 mg per dL. If that is not achieved, a PSK9 inhibitor should be considered.

Regarding PSK9 inhibitors, it is notable that the guideline cautions that “the long-term safety (more than 3 years) is uncertain and cost effectiveness is low at mid-2018 list prices.” Although the previous guideline was silent on the question of monitoring lipid levels, this one recommends regular monitoring (at least once per year) to verify adherence to the medication and to estimate the percentage reduction in LDL level. It is also worth noting which organizations were not among the 12 that endorsed this guideline: the American Academy of Family Physicians (AAFP) and the American College of Physicians (ACP). This is reminiscent of the recent, aggressive hypertension guidelines from the ACC/AHA that the AAFP and ACP also did not participate in or endorse.

Study design: Practice guideline

Funding source: Government

Setting: Various (guideline)

Reference: Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018;S0735-1097(18)39034-X.

Editor's Note: Dr. Ebell is Deputy Editor for Evidence- Based Medicine for AFP and cofounder and Editor-in-Chief of Essential Evidence Plus.