Patient-Oriented Evidence That Matters
Overview of New ACC/AHA Lipid Guidelines
Am Fam Physician. 2019 Jun 1;99(11):716-717.
What do cardiologists recommend for the management of hyperlipidemia?
These updated guidelines, made without any input from primary care physicians who manage most patients with hyperlipidemia, are more complex than the 2013 guidelines and will likely lead to even more recommendations for statins, ezetimibe (Zetia), and PSK9 inhibitors. Rather than a “fire and forget” strategy involving a risk-based prescription of a moderate- or high-intensity statin, we are supposed to go back to monitoring low-density lipoprotein (LDL) levels and targeting a percentage reduction in LDL cholesterol—and in very high-risk patients targeting an LDL level of less than 70 mg per dL (1.81 mmol per L). (Level of Evidence = 1a−)
This is an update to the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines, which were the first to base treatment decisions primarily on the 10-year risk of an atherosclerotic cardiovascular disease (ASCVD) event rather than on specific LDL targets. This guideline reemphasizes regularly measuring lipids and a return to an LDL target for assessing effectiveness and deciding when to prescribe one of the new and pricey PSK9 inhibitors ($14,000 to $15,000 per year at http://www.goodrx.com, December 1, 2018). Statins are divided into high intensity (atorvastatin [Lipitor], 40 to 80 mg; rosuvastatin [Crestor], 20 to 40 mg), moderate-intensity (atorvastatin, 10 to 20 mg; simvastatin [Zocor], 20 to 40 mg; rosuvastatin, 5 to 10 mg), and low-intensity (simvastatin, 10 mg) groups. For primary prevention in people 20 to 39 years of age, the guidelines recommend an assessment of the lifetime risk of ASCVD as a way to frighten patients into compliance with lifestyle changes. For people 20 to 39 years of age with LDL levels greater than 160 mg per dL (4.14 mmol per L) or a family history of premature ASCVD, a statin is recommended. For patients 40 years and older, a high-intensity statin is recommended
Editor's Note: Dr. Ebell is Deputy Editor for Evidence-Based Medicine for AFP and cofounder and Editor-in-Chief of Essential Evidence Plus, published by Wiley-Blackwell.
POEMs (patient-oriented evidence that matters) are provided by EssentialEvidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, please see http://www.essentialevidenceplus.com. Copyright Wiley-Blackwell. Used with permission.
For definitions of levels of evidence used in POEMs, see https://www.essentialevidenceplus.com/product/ebm_loe.cfm?show=oxford.
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A collection of POEMs published in AFP is available at https://www.aafp.org/afp/poems.
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