- 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 < 40 years
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Age ≥ 40 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 HDL and Triglyceride Levels in Adults |
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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 predisposes affected individuals to very high LDL levels which in turn greatly increases their risk of ASCVD
- FH may be heterozygous (one affected allele) or homozygous (two affected allele)
- Heterozygous FH occurs in about 1 out of every 250 people worldwide. Homozygous FH is rare, occurring in 1 out of 160,000 to 1 out of 1,000,000 people worldwide.
- Adults with FH typically have LDL levels of ≥ 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
- Coronary artery calcium scoring, commonly abbreviated CAC, is a CT scan that detects calcification in the coronary arteries
- The test returns a score that quantifies the degree of calcification present
- Atherosclerotic plaques calcify over time, so the CAC score is a reflection of the amount of atherosclerosis present in the arteries (see coronary artery calcium scoring for more)
- The AHA 2018 CAC scoring recommendations are presented below
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 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 the Framingham risk calculators have both been shown to overestimate cardiovascular risk in trials. A recent study in the Annals of Internal Medicine found that 4 different risk 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