In November 2013, the AHA in association with the ACC released novel guidelines regarding the management of hyperlipidemia.  These guidelines essentially separate management into two broad categories; primary, and secondary prevention.

Primary prevention is separated into patients with LDL-C > 190mg/dL, patients with diabetes mellitus (type I or II) aged 40-75, with the remainder of patients stratified based on their estimated 10 year ASCVD risk.

In a strongly positive move, all patients with a history of ASCVD, defined as a history of MI, stable or unstable angina, any arterial revascularization, stroke, TIA, or peripheral arterial disease of atherosclerotic origin, are recommended to be prescribed a high-intensity statin unless contraindicated or intolerant.

Statins have been categorized into high-, moderate-, and low-intensity based on their predicted percentage reduction in LDL-C. Below is a table outlining these categories and the statins which satisfy each treatment criterion.

 

High-intensity Moderate-intensity Low-intensity
Daily dose lowers LDL–C on average, by approximately ≥50% Daily dose lowers LDL–C on average, by approximately 30% to <50% Daily dose lowers LDL–C on average, by <30%
Atorvastatin (40)–80mgRosuvastatin 20 (40)mg Atorvastatin 10 (20)mgRosuvastatin (5) 10mg

Simvastatin 20–40mg

Pravastatin 40 (80)mg

Lovastatin 40 mg

Fluvastatin XL 80 mg

Fluvastatin 40 mg bid

Pitavastatin 2–4 mg

Simvastatin 10 mgPravastatin 10–20mg

Lovastatin 20 mg

Fluvastatin 20–40 mg

Pitavastatin 1 mg

 

 

Below is an outline of the new guideline, summarized in a flow chart.

StatinChartpic

 

 

Changes to statin therapy guidelines for risk reduction of atherosclerotic cardiovascular disease (ASCVD)

What does this mean for the way we practice/prescribe?

  • Anyone with history of ASCVD should be prescribed the highest tolerable dose of a statin
  • Risk stratify patients with normal LDL-C using the excel spreadsheet attached and treat accordingly
  • 10 year ASCVD risk 5% < 7.5% are suitable for moderate intensity statin dosage
  • No recommendation for primary prevention in patients over 75
  • Secondary prevention in patients over 75 should step down from high intensity to moderate intensity.
  • LDL-C > 190mg/dL requires high intensity treatment
  • Reduced need for LDL-C monitoring
  • Reduce statin dosage if LDL-C < 40mg/dL
  • Obtain ALT prior to initiation of statin therapy

Difficulties these changes will bring

  • No goal orientated therapy (lack of LDL-C monitoring)
    • Must continue to advocate diet and exercise
  • Other lipid –lowering agents are not recommended under the revised guidelines
  • No protocol for patients who experience ASCVD despite maximal statin therapy

 

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