12 - Treatment Guidelines Overview: American Heart Association/American College of Cardiology/Multisociety Guideline and Updates

Abstract

The 2018 American Heart Association and American College of Cardiology (AHA/ACC) Multisociety lipid guideline uses a risk-based approach for recommending lipid-lowering therapy. This means that lipid-lowering medications proven to lower risk most are prioritized; thus, statin therapy is the cornerstone of lipid-lowering therapy. This also means that medications without clear risk reduction are de-prioritized. In secondary prevention patients, not only is statin therapy recommended, but the use of high-intensity statin therapy. The guidelines recommend further risk stratification even in patients with also clinical atherosclerotic cardiovascular disease (ASCVD) because risk is heterogeneouss. Some patients with ASCVD are at even higher risk of recurrent events and require even more-intensive low-density lipoprotein cholesterol (LDL-C)–lowering therapy with addition of evidence-based nonstatin therapy to high-intensity statin therapy. These patients are termed “very-high-risk ASCVD” and are identified by the presence of two or more major ASCVD events or at least one major ASCVD event and two or more high-risk conditions. Approximately 45%–55% of patients with ASCVD would be classified as very high risk. The guidelines recommends that clinicians can consider the use of evidence-based nonstatin therapies (ezetimibe and proprotein convertase subtilisin/kexin type 9 inhibitor [PCSK9i]) if LDL-C remains ≥70 mg/dL and, in the case of PCSK9i, non–high-density lipoprotein cholesterol (non–HDL-C) ≥100 mg/dL. The primary prevention of ASCVD begins with a heart-healthy diet and regular physical activity, but lipid-lowering therapy should be used in accordance with ASCVD risk. The guidelines also discusses treatment in special populations such as children and adolescents and patients with very high cholesterol, diabetes mellitus, or hypertriglyceridemia. The 2018 AHA/ACC Multisociety lipid guidelines rigorously evaluated data to provide the best available recommendations for lipid management. Major recommendations and the rationale behind those recommendations are discussed for each of the major treatment groups.