Table 1. Definition of ASCVD Clinical ASCVD is defined ...

Key Message 2: Statins are first-line agents for the primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD). Statin intensity and treatment goals should be determined based on presence of ASCVD or ASCVD risk factors.

Both the American College of Cardiology/American Heart Association (ACC/AHA) and National Lipid Association (NLA) emphasize the importance of lifestyle modification as an initial approach to ASCVD risk reduction.1,2 When therapeutic lifestyle changes alone are inadequate, they recommend the use of statins as initial pharmacologic therapy for the primary and secondary prevention of ASCVD.

The ACC/AHA and NLA guidelines share definitions for clinical ASCVD (Table 1) and for the intensity of statin therapies (Table 2) derived from doses used in randomized controlled trials (RCTs).1,2

Table 1. Definition of ASCVD.1,2 Clinical ASCVD is defined as the history of 1 or more of the following morbidities:

? Myocardial infarction/ Acute coronary syndrome

? Stable or unstable angina ? Coronary or other arterial revascularization ? Stroke ? Transient ischemic attack ? Peripheral artery disease presumed to be

of atherosclerotic origin

Table 2. Intensity of statin therapy.1,2

High

Moderate

Daily dosage LDL-C

Daily dosage LDL-C

50%

30% to < 50%

Atorvastatin 10-20 mg

Fluvastatin 40 mg BID

Fluvastatin XL 80 mg

Atorvastatin 40-80 mg

Lovastatin 40 mg

Rosuvastatin 20-40 mg

Pitavastatin 2-4 mg

Pravastatin 40-80 mg

Rosuvastatin 5-10 mg

Simvastatin 20-40 mg

Individual responses may vary

BID=twice per day; LDL-C=low-density lipoprotein cholesterol

ACC/AHA recommendations: According to the ACC/AHA, there are 4 groups of patients that could benefit from statin therapy, of moderate or high intensity.1

The ACC/AHA does not recommend treating to a target LDL-C level, stating that most of the RCTs evaluated statins at fixed doses.1 There is no RCT evidence in favor of targeting 1 specific LDL-C level over another (Table 3). Addition of a non-statin drug to further reduce LDL-C levels requires careful consideration by physician and is only recommended in very high risk patients (those with clinical ASCVD, LDL-C 190 mg/dL, or DM).

Table 3. ACC/AHA recommendations for initiating statin therapy.1

Statin benefit group

Sub-groups

Recommended therapy

Individuals with clinical ASCVD

75 years of age > 75 years of age

High intensity Moderate intensity

Individuals with primary elevations of LDL-C 190 mg/dL

High intensity

Individuals 40-75 years of age with diabetes, LDL-C 70-189 mg/dL

10-year ASCVD risk 7.5% High intensity 10-year ASCVD risk < 7.5% Moderate intensity

Individuals 40-75 years of age

without clinical ASCVD or diabetes, LDL-C 70-189 mg/dL, estimated 10year ASCVD risk 7.5%

Moderate to high intensity

ASCVD=atherosclerotic cardiovascular disease; LDL-C=low-density lipoprotein cholesterol

An estimated 10-year risk for ASCVD is calculated using the AHA pooled cohort equations,1 available on the ACC/AHA Website. The risk calculator takes into account gender, age, race, total cholesterol, high-density lipoprotein cholesterol (HDL-C), blood pressure (BP), use of anti-hypertensives, diabetes, and smoking status.1

1

Last reviewed April 2016

NLA recommendations:

The NLA guideline identifies risk categories based on the number of ASCVD risk factors and other underlying risk indicators.2 Unlike the ACC/AHA, the NLA specifies target cholesterol levels for each category.1,2 The NLA also recommends addition of a non-statin drug to help achieve LDL-C goal if statin therapy alone is insufficient.

Table 4. NLA recommended criteria for ASCVD risk assessment, treatment goals for atherogenic cholesterol, and levels at which to consider drug therapy.2

Treatment goal

Consider drug therapy

Risk category

Criteria

Non-HDL-C (mg/dL)

Non-HDL-C (mg/dL)

LDL-C (mg/dL)

LDL-C (mg/dL)

Low

? 0-1 major ASCVD risk factors ? Consider other risk indicators, if known

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