- ACRONYMS AND DEFINITIONS
- ABI - Ankle-brachial index
- AHA - American Heart Association
- ACC - American College of Cardiology
- ACS - Acute coronary syndrome defined as myocardial infarction or unstable angina
- ADA - American Diabetes Association
- ASCVD - Atherosclerotic cardiovascular disease
- CAC - Coronary artery calcium scoring
- CK - Creatine kinase
- CVD - Cardiovascular disease
- FH - Familial hypercholesterolemia (genetic condition that causes very high LDL levels)
- HDL - High density lipoprotein
- LDL - Low density lipoprotein
- Non-HDL cholesterol = Total cholesterol - HDL cholesterol
- Primary prevention - measures taken to prevent a disease in a patient who has not been diagnosed with the disease
- Secondary prevention - prevention of the recurrence of an event (ex. heart attack) or illness (ex. cancer) after the underlying disease has already been established in the patient
- USPSTF - U.S. Preventive Services Task Force
- ASCVD DEFINITION
- The AHA 2018 guidelines define atherosclerotic cardiovascular disease (ASCVD) as a history of any of the following:
- Acute coronary syndrome
- Myocardial infarction
- Stable or unstable angina
- Coronary or other arterial revascularization
- Stroke or transient ischemic attack (TIA)
- Peripheral artery disease including aortic aneurysm [5]
- STATIN INTENSITY CHART
High-intensity statin therapy (lowers cholesterol by ≥50%) |
Moderate-intensity statin therapy (lowers cholesterol by 30 - 50%) |
Low-intensity statin therapy (lowers cholesterol by < 30%) |
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- SCREENING RECOMMENDATIONS
AHA/ACC 2018 Screening Recommendations |
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Adults
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Children
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USPSTF Screening Recommendations |
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Women
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Men
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Children and adolescents less than 20 years old
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- PRIMARY PREVENTION RECOMMENDATIONS
AHA/ACC 2018 Primary Prevention Recommendations |
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Any patient with diabetes
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Age 0 - 19 years
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Age 20 - 75 years old and LDL ≥ 190 mg/dl
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Age 20 - 39 years and LDL 70 - 189 mg/dl
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Age 40 - 75 years and LDL 70 - 189 mg/dl
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Age ≥ 75 years and LDL 70 - 189 mg/dl
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Risk enhancers |
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USPSTF 2022 Primary Prevention Recommendations |
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Prescribe a statin to patients who meet all of the following criteria:
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A statin may be beneficial in some patients who meet all of the following criteria:
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Age ≥ 76 years
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- SECONDARY PREVENTION RECOMMENDATIONS
AHA/ACC 2018 Secondary Prevention Recommendations |
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Risk categories
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Age ≤ 75 years and not at very-high risk
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Age > 75 years and not at very-high risk
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Any age and very high-risk ASCVD
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ASCVD Secondary Risk Categories |
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Major ASCVD events |
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High-risk conditions |
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- DIABETES RECOMMENDATIONS
ADA Lipid Treatment Recommendations for Adults with Diabetes |
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Age 20 - 39 years
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Age 40 - 75 years
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Age > 75 years
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ADA ASCVD Risk Factors |
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ADA Lipid Treatment Recommendations for Youth with Type 1 DM |
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Screening
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Treatment
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ADA Lipid Treatment Recommendations for Youth with Type 2 DM |
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Screening
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Treatment
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ADA Recommendations for High Triglyceride Levels in Adults |
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Fasting triglycerides ≥ 500 mg/dl
Triglycerides 175 - 499 mg/dl
Patients with ASCVD or ASCVD risk factors on a statin with controlled LDL and triglycerides 135 - 499 mg/dL
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ADA Recommendations for Triglyceride Levels in Youth with Type 2 DM |
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AHA/ACC 2018 Primary Prevention in Diabetes Recommendations |
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Age 20 - 39 years
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Age 40 - 75 years
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Age > 75 years
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Diabetes-specific Risk Enhancers |
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- FAMILIAL HYPERCHOLESTEROLEMIA (FH)
- Overview
- Familial hypercholesterolemia (FH) is a genetic condition that affects LDL receptors and their ability to remove cholesterol from the blood. Patients with FH have high LDL levels throughout life, predisposing them to early cardiovascular disease. The FH gene is located on chromosome 19, and affected individuals may have either one abnormal allele (heterozygous) or two (homozygous). Heterozygous FH is prevalent in 1 out of every 250 people worldwide, while homozygous FH is rare, occurring in 1 out of 160,000 to 1,000,000 people.
- Adults with FH typically have LDL levels ≥ 190 mg/dl. Children with FH generally have LDL levels ≥ 160 mg/dl, but levels may be lower in the pre-teen years.
- See FH diagnostic criteria for more [6]
AHA/ACC 2018 Familial Hypercholesterolemia (FH) Recommendations |
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Age 0 - 19 years
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Age 20 - 29 years with FH
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Age 30 - 75 years with FH
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- HYPERTRIGLYCERIDEMIA
AHA/ACC 2018 Hypertriglyceridemia Recommendations |
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Triglyceride ranges
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Age 20 - 39 with moderate hypertriglyceridemia
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Age 20 - 39 with severe hypertriglyceridemia
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Age 40 - 75 with moderate hypertriglyceridemia
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Age 40 - 75 with severe hypertriglyceridemia
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- CAC SCORING
- Overview
- Atherosclerotic plaques calcify over time, making calcification, which is easily detected on a CT scan, a marker of coronary artery disease. Coronary artery calcium scoring, commonly abbreviated CAC, is a procedure where a CT scan quantifies the amount of calcium in coronary arteries. The results are then converted into a score using a standardized system, with higher values indicating more atherosclerosis (see coronary artery calcium scoring for more).
- The AHA 2018 recommendations for incorporating CAC scores into treatment decisions are presented below, along with guidance on when to perform CAC screening.
AHA 2018 CAC Treatment Recommendations |
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Intermediate and borderline risk patients (see primary prevention above)
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AHA 2018 CAC Screening Recommendations |
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The AHA states that CAC screening may be appropriate in patients who may benefit from knowing their score is zero. Those patients include the following:
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- RISK FACTORS FOR ADVERSE EFFECTS FROM STATINS
- For patients with any of the following risk factors, a lower intensity statin may be considered:
- Multiple or serious comorbidities, including impaired kidney or liver function
- History of previous statin intolerance or muscle disorders
- Unexplained ALT elevations > 3 times upper limits of normal
- Patient characteristics or concomitant use of drugs affecting statin metabolism
- Age > 75 years of age
- History of hemorrhagic stroke (see statins in hemorrhagic stroke)
- Asian ancestry [1]
- MONITORING STATIN THERAPY
- Lipid profile
- Recheck lipid profile 4 - 12 weeks after initiating or changing statin therapy and every 3 - 12 months thereafter, depending on need [5]
- Liver function tests
- Creatine kinase
- STATIN SIDE EFFECTS
- CARDIOVASCULAR RISK CALCULATORS
- Calculators
- AHA Cardiovascular Risk Calculator
- Framingham risk calculator (NOTE: The Framingham calculator cannot be used for diabetics)
- Criticisms
- The AHA and Framingham calculators have been shown to overestimate cardiovascular risk in trials. One study found that 4 different calculators (AHA and 3 Framingham-based calculators) overestimated cardiovascular events by 37 - 154% in men and 8 - 67% in women. [PMID 25686167]
- BIBLIOGRAPHY
- 1 - PMID 24222016 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, Circulation (2014)
- 2 - USPSTF website
- 3 - PMID 27046161 - ACC Non-statin recommendations for LDL
- 4 - PMID 28886926 - 2017 Focused Update of the 2016 ACC Expert Consensus Decision Pathway on the Role of Non-Statin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk JACC (2017)
- 5 - PMID 30423391 - 2018 AHA/ACC Guideline on the Management of Blood Cholesterol: Executive Summary, J Am Coll Cardiol, (2018)
- 6 - FH Foundation website
- 7 - ADA Standards of Medical Care in Diabetes 2020
- 8 - PMID 36507650 - Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes-2023, Diabetes Care (2023)
- 9 - ADA Standards of Medical Care in Diabetes, Diabetes Care (2023)