Atherosclerotic cardiovascular disease (ASCVD) is a disease in which plaque, made up of fat, cholesterol, calcium, and other substances, builds up inside your arteries. Over time, the plaque will block the flow of oxygen-rich blood to your organs and other parts of your body leading to serious problems, including heart attacks and strokes. The primary treatment for high blood cholesterol and atherosclerosis is lifestyle changes, the most important include:
1. Adhering to a heart-healthy diet
2. Regular exercise habits
3. Maintenance of a healthy weight
4. Avoidance of tobacco and alcohol products
However, you may need medications if lifestyle changes are not enough. The most important drug therapy being a class of medications called “statins.”
Recently, there was an update of the recommendations for the treatment of blood cholesterol to reduce ASCVD risk. For this guideline, ASCVD includes coronary heart disease, stroke, and peripheral arterial disease, all of presumed atherosclerotic origin. The new guidelines are intended to provide evidence-based recommendations to determine who should get statin therapy and the appropriate statin therapy intensity.
What are the Important Questions?
#1 – Which groups of people would most likely benefit from statin therapy?
#2 – How can we determine someone’s 10-year ASCVD risk, in order to identify higher risk people for statin therapy?
#3 – What is the appropriate “statin” and what are the low-density lipoprotein (LDL) cholesterol goals?
What are the Recommendations?
#1 – Identifying Four Statin Benefit Groups
Group 1: People with known ASCVD (including previously diagnosed myocardial infarction or “heart attack,” coronary heart disease, stroke, or peripheral arterial disease, all of atherosclerotic origin)
For “primary” prevention (people without ASCVD, in order to prevent the disease):
Group 2: ≥21 years old with LDL ≥190 mg/dL (≥4.9 mmol/L)
Group 3: 40-75 years old with LDL 70-189 mg/dL (1.8-4.8 mmol/L) and diabetes
Group 4: 40-75 years old with LDL 70-189 mg/dL (1.8-4.8 mmol/L) and no diabetes, but a greater than 7.5% 10-year ASCVD risk (see #2 – Estimating a 10-year ASCVD Risk)
#2 – Estimating a 10-year ASCVD Risk
In “primary” prevention, the use of a new calculator to estimate 10-year ASCVD risk (including the risk of first nonfatal myocardial infarction or “heart attack,” coronary heart disease death, nonfatal or fatal stroke) is now recommended:
For people in Group 4, this new calculator identifies high risk people for statin therapy.
#3 – Identifying the Intensity of Statin Therapy and Specific LDL Cholesterol Goals
1. When statin therapy is started, most people should be on a moderate-intensity* or high-intensity* statin.
*Moderate-Intensity Statin Therapy
Atorvastatin 10-20 mg
Rosuvastatin 5-10 mg
Simvastatin 20-40 mg
Pravastatin 40-80 mg
Lovastatin 40 mg
Fluvastatin XL 80 mg
Pitavastatin 2-4 mg
*High-Intensity Statin Therapy
Atorvastatin 40-80 mg
Rosuvastatin 20-40 mg
2. Once statin therapy is started, there are no longer any specific LDL cholesterol goals.
3. Nonstatin cholesterol-lowering medications, if added to statin therapy, are no longer recommended due to lack of additional ASCVD risk reduction.
What is the Controversy?
The new guidelines created substantial confusion, controversy, and debate among healthcare providers, patients, and the media. One of the major changes was just being on a statin, if determined to be beneficial, rather than an emphasis on specific LDL cholesterol targets or goals. So, the “treat to target” or “lower the LDL the better” approach to blood cholesterol management is no longer recommended.
Additionally, there has been concern that many people who were not on a statin previously will now be prescribed a statin—thus, dramatically increasing the total number of people taking a statin. This is true. However, cardiovascular disease is the world’s biggest killer so anything we can do to prevent or treat cardiovascular disease will save countless lives and precious healthcare resources.
The thoroughness and strong evidence-based foundation of these recommendations leave little doubt that if you are in one of the four statin benefit groups then statin therapy should be considered.
What You Need To Know
1. Adhere to a heart-healthy lifestyle!
2. Statin therapy is recommended for groups of people proven to have a benefit.
3. Statin therapy is safe when used in properly selected people and appropriately monitored.
4. Engage in a doctor-patient discussion before initiating statin therapy.
Decisions about high blood cholesterol management should carefully consider all the characteristics and circumstances of each individual person. For all people with high blood cholesterol, the benefits of a healthy diet, regular exercise, weight control, and avoidance of tobacco products cannot be overemphasized. Take control of your health!