2017 ACC Recommendations for Non-Statin Therapy
- Lloyd-Jones DM, Morris PB, Ballantyne CM, et al.
- 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: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. J Am Coll Cardiol 2017;Sep 5:[Epub ahead of print].
The following are key points to remember about the 2017 Focused Update of the 2016 American College of Cardiology (ACC) Expert Consensus Decision Pathway on the Role of Non-Statin Therapies for Low-Density Lipoprotein (LDL)-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease (ASCVD) Risk:
- At the time of the 2013 ACC/AHA Cholesterol guidelines, the panel found no supporting evidence for the routine use of non-statin drugs in combination with statins for the reduction of ASCVD events. Three years later, the ACC published its first expert consensus decision pathway related to the role of non-statin therapies for LDL-cholesterol lowering. Since then, additional evidence, in particular related proprotein convertase subtilisin/kexin 9 (PCSK9) inhibitors, has been published. The revised recommendations (published in September 2017) pertain to patients with clinical ASCVD with or without comorbidities on statin therapy for secondary prevention.
- The writing committee did not provide new or revised recommendations related to primary prevention groups (patients with LDL-C <190 mg/dl with or without diabetes or patients without ASCVD and an LDL ≥190 mg/dl) in regards to the use of PCSK9 inhibitors or ezetimibe.
- Thresholds for consideration of ASCVD risk reduction are percent reduction in LDL (current LDL compared to baseline LDL). Absolute LDL or non–high-density lipoprotein (HDL) levels may be considered for each of the four statin benefit groups. The groups are: 1) adults with clinical ASCVD; 2) adults with an LDL ≥190 mg/dl; 3) adults ages 40-75 years without ASCVD with diabetes mellitus (DM) and an LDL between 70 and 189 mg/dl; and 4) adults between ages 40 and 75 years without ASCVD or DM, with an LDL between 70 and 189 mg/dl, and an estimated 10-year risk for ASCVD of ≥7.5% (using the pooled risk equation). Consideration of non-statin therapies to provide adequate percent LDL lowering was based on evidence from two trials: 1) FOURIER, which included patients with clinical ASCVD with or without DM; and SPIRE-2, which included high-risk primary prevention patients and patients with familial hypercholesterolemia.
- Percent risk reduction for patients with clinical ASCVD, with or without comorbidities, is recommended to be ≥50% for all patients with clinical ASCVD and a baseline LDL level. Consideration for an LDL <70 mg/dl or a non-HDL >100 mg/dl can be given as well. The recommendations to consider non-statin therapies to all patients with clinical ASCVD are based on evidence from FOURIER and IMPROVE-IT trials.
- Addition of non-statin therapies to maximally tolerated statin therapy is recommended to be considered among patients with clinical ASCVD when additional LDL lowering is desired. Addition of either ezetimibe or a PCSK9 inhibitor should also factor in patient preferences, costs, and route of administration in addition to percent of LDL lowering desired. For <25% of additional LDL lowering, ezetimibe may be preferred, while in patients who require >25% additional LDL lower, a PCSK9 inhibitor may be preferred. Periodic measurement of lipids (to determine adherence and response to therapy) continues to be recommended including at the start of treatment, 4-12 weeks after initiation of a statin, and thereafter every 3-12 months as clinically indicated. The writing committee recommended monitoring lipids at 4-12 weeks after modification to LDL-lowering therapy, including the addition of a non-statin therapy.
Keywords: Atherosclerosis, Cardiovascular Diseases, Cholesterol, Cholesterol, LDL, Consensus, Decision Making, Diabetes Mellitus, Dyslipidemias, Genetic Diseases, Inborn, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hyperlipoproteinemia Type II, Life Style, Lipids, Lipid Metabolism, Inborn Errors, Lipoproteins, Patient Compliance, Primary Prevention, Proprotein Convertases, Risk Assessment, Risk Factors, Risk Reduction Behavior, Secondary Prevention, Subtilisins
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