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In many cases direct quotes are used from the primary reference:
Stone NJ, Robinson J, Lichtenstein AH, Bairey Merz CN, Lloyd-Jones DM, Blum
CB, McBride P, Eckel RH, Schwartz JS, Goldberg AC, Shero ST, Gordon D, Smith SC
Jr, Levy D, Watson K, Wilson PW. 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. J Am Coll Cardiol. 2013 Nov 7. pii:
S0735-1097(13)06028-2. doi: 10.1016/j.jacc.2013.11.002.
Four 'Statin Benefit Groups' have been identified that have the potential to
reduce the risk of atherosclerotic cardiovascular disease. The benefit of
therapy has been found to clearly exceed the potential for adverse effects in
adults. The four groups are as follows:
- Individuals with clinical ASCVD (Secondary prevention): Clinical ASCVD
Atherosclerotic Cardiovascular Disease is defined
by the inclusion criteria for the secondary prevention statin RCTs (acute
coronary syndromes, or a history of MI, stable or unstable angina, coronary
or other arterial revascularization, stroke, TIA, or peripheral arterial
disease presumed to be of atherosclerotic origin).
- Individuals with primary elevations of LDL-C
 190 mg/dL.
- Individuals 40 to 75 years of age with diabetes and LDL-C 70-189 mg/dL.
For the primary prevention of ASCVD in individuals with diabetes (diabetes
mellitus type-1 and type-2), estimated 10-year ASCVD risk can also be used
to guide the intensity of statin therapy.
- Individuals without clinical ASCVD or diabetes who are 40 to 75 years of
age with LDL-C 70- 189 mg/dL and an estimated 10-year ASCVD risk of 7.5% or
higher. Data has shown that statins used for primary prevention
have substantial ASCVD risk reduction benefits across the range of LDL-C
levels of 70-189 mg/dL.
Flowchart:1
Initial steps: Counseling on a
heart healthy lifestyle forms the foundation of ASCVD prevention.
Pooled Cohort equations: Individuals not receiving cholesterol-lowering drug therapy,
should have their
estimated 10-year ASCVD risk calculated initially, and then every 4 to 6 years in individuals aged 40 to 75 years
without clinical Atherosclerotic Cardiovascular Disease or diabetes and with LDL-C 70-189 mg/dL.
Decision point:
1] Adults age >21 years old and a candidate for statin therapy [if Yes] AND
Diagnosis: Clinical
ASCVD
[if YES] --> 2 paths:
(a) Age 75 years -
[if YES] Start High-intensity statin (Use Moderate-intensity statin
if not a candidate for high-intensity
statin).
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Background: (direct quotes) 1
Moderate-intensity statin therapy should be used in individuals in
whom high-intensity statin therapy would otherwise be recommended when
characteristics predisposing them to statin associated
adverse effects are present. Characteristics predisposing individuals to statin
adverse effects include, but are not limited to:
- Multiple or serious
comorbidities, including impaired renal or hepatic function.
- History of previous statin intolerance or muscle disorders.
- Unexplained ALT elevations >3 times ULN.
- Patient characteristics or
concomitant use of drugs affecting statin metabolism.
- >75 years of age.
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(b)
Age >75y or if not candidate for high-intensity statin-->[if
YES] start
moderate-intensity statin.
Decision point:
2] LDL-C
190? -->[if
YES] --> Start high-intensity statin (Moderate-intensity statin
if not a candidate for high-intensity statin).
Decision point:
3] Diabetes type 1 or 2 AND age 40-75y
AND LDL-C 70-189 mg/dL.? [ if YES] --> Start Moderate-intensity statin
[support for high-intensity: "Giving a maximally tolerated statin intensity
should receive primary emphasis because it most accurately reflects the data
that statins reduce the relative risk of ASCVD events similarly in individuals
with and without diabetes, and
in primary and secondary prevention in those with diabetes, along with evidence
that high-intensity
statins reduce ASCVD events more than moderate-intensity statins."]
Decision point:
4] No to all above? -->[if
YES] Estimate the 10-year ASCVD risk with
the Pooled Cohort
Equations -->
Is the estimated 10-y risk 7.5
AND age 40-75 [if YES] --> Start Moderate
to high intensity statin.
IF NO e.g. estimated 10-y risk <7.5 --> ASCVD
prevention benefit of statin therapy may be less clear in other groups. In
selected individuals, consider the following:
- Review additional factors influencing ASCVD risk
- Review potential ASCVD treatment risks, benefits and adverse effects
- Review potential drug-drug interactions
- Determine
patient preferences for statin treatment.
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Statin therapy: monitoring therapeutic response and adherence:
Flowchart:
- Assess medication and lifestyle adherence - fasting lipid panel etc.
Was the anticipated response achieved ? [E.g.
high-intensity statin regimen:
50 percent reduction
in LDL-C from untreated baseline or moderate-intensity statin therapy- LDL-C
reduction of ~30 - <50% from untreated baseline]
- [if YES] --> - reinforce
continued adherence --> follow-up in 3 to 12 months.
- [if NO] --> (Less than
anticipated result) --> [Was there intolerance to the recommended statin
dose - [YES / NO] -->
- [if YES] - Review the
section on management of statin intolerance (Stone NJ et al.
2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to
Reduce Atherosclerotic Cardiovascular Risk in Adults: ....)
- [if NO] - reinforce
medication adherence and adherence to intensive lifestyle changes.
Also exclude secondary causes of hypercholesterolemia.
Follow-up in 4 to 12 weeks.
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-
Stone NJ, Robinson J, Lichtenstein AH, Bairey Merz CN, Lloyd-Jones
DM, Blum CB, McBride P, Eckel RH, Schwartz JS, Goldberg AC, Shero ST,
Gordon D, Smith SC Jr, Levy D, Watson K, Wilson PW. 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. J Am Coll Cardiol. 2013 Nov 7. pii: S0735-1097(13)06028-2.
doi: 10.1016/j.jacc.2013.11.002.
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Goff DC Jr, Lloyd-Jones DM, Bennett G, O'Donnell CJ, Coady S,
Robinson J, D'Agostino RB Sr, Schwartz JS, Gibbons R, Shero ST,
Greenland P, Smith SC Jr, Lackland DT, Sorlie P, Levy D, Stone NJ,
Wilson PW. 2013 ACC/AHA Guideline on the Assessment of Cardiovascular
Risk: A Report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013
Nov 12. pii: S0735-1097(13)06031-2. doi: 10.1016/j.jacc.2013.11.005.
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Lloyd-Jones DM, Leip EP, Larson MG, D'Agostino RB, Beiser A, Wilson
PW, Wolf PA, Levy D. Prediction of lifetime risk for
cardiovascular disease by risk factor burden at 50 years of age.
Circulation. 2006 Feb 14;113(6):791-8. Epub 2006 Feb 6.
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