2019;139:e1082–e1143. Guideline developed by participants without relevant financial ties to industry? A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. The guideline on Management of Blood Cholesterol was developed by the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and was categorized as Affirmation of Value by the American Academy of Family Physicians. As with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations. The American College of Cardiology/American Heart Association (ACC/AHA) task force on clinical practice guidelines has updated its 2013 cholesterol guideline. Published source: J Am Coll Cardiol. A CAC score of 1 to 99 suggests statin therapy, particularly for patients 55 years and older. Based on high-quality evidence from randomized controlled trials (RCTs), high-intensity statin therapy should be instituted with a goal of lowering LDL-C levels by 50% or more in patients with ASCVD up to 75 years of age. As a member, you'll receive a variety of exclusive products, programs, services, and discounts totaling more than $3,800 in member savings. Based on nonrandomized trials, patients at very high risk (history of multiple ASCVD events or one event with multiple high-risk comorbidities) should be considered for treatment with maximally tolerated statin doses and ezetimibe (Zetia) before considering the addition of a proprotein convertase subtilisin/kexin type 9 inhibitor. / afp / Vol. This clinical content conforms to AAFP criteria for continuing medical education (CME). The guideline is a compilation of the most important studies and guidelines for … 2019;139:e1046– e1081. Immediate, unlimited access to all AFP content. Yes. Adults 40-75 years of age with diabetes mellitus and an LDL-C 70-189 mg/dL should be treated with moderate-intensity statin therapy. Editor’s Note: Similar to the 2013 ACC/AHA cholesterol guideline, this guideline has some utility for family physicians but is limited by several recommendations that will be challenging to implement and lack patient-oriented evidence. Recommendations are based on the best available evidence from randomized controlled trials of cholesterol-lowering therapies and other sources of evidence. Learn About the AAFP Criteria for Endorsement of Clinical Practice Guidelines Developed by External Organizations. Yes, Guideline developed by participants without relevant financial ties to industry? Match season is complex—especially this year. Cholesterol Management: ACC/AHA Updates Guideline • A nonfasting plasma lipid profile can be obtained to estimate ASCVD risk and document baseline LDL-C in adults 20... • Maximally tolerated statin therapy is recommended for patients 20 to … Based on moderate-quality evidence from nonrandomized studies, the 10-year risk of a first ASCVD event can be assessed in patients 40 to 75 years of age with diabetes and an LDL-C level of 70 to 189 mg per dL. If treatment is not tolerated, then moderate-intensity therapy should be used with a goal of achieving a 30% to 49% reduction in LDL-C levels. Copyright © 2019 by the American Academy of Family Physicians. Circulation. Lifestyle therapy should be the primary intervention for metabolic syndrome. Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP. A 30% or greater reduction in LDL-C levels is recommended, and in high-risk patients a 50% or greater reduction is recommended. Want to use this article elsewhere? Adults 40-75 years of age with an LDL-C 70-189 mg/dL without clinical ASCVD or diabetes and an estimated ten-year ASCVD risk 5- 7.4% may consider moderate intensity statin therapy if there are additional risk factors. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Get Permissions, Access the latest issue of American Family Physician. Moderate-quality evidence from nonrandomized studies recommends estimating the 10-year ASCVD risk of a first fatal or nonfatal myocardial infarction or stroke by using the race and sex-specific pooled cohort equations. The more LDL-C is reduced on statin therapy, the greater will be subsequent risk reduction. The 2018 guideline narrows the use of the atherosclerotic cardiovascular disease (ASCVD) risk calculator, provides more guidance on the use of risk-enhancing factors in making statin therapy decisions, and recommends therapy options for achieving low-density lipoprotein cholesterol (LDL-C) targets. PCNA guideline on the management of blood cholesterol: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. To be effective, the recommendations must be implemented. Choose a single article, issue, or full-access subscription. • Moderate-intensity statin therapy should be initiated without calculating a 10-year ASCVD risk for patients 40 to 75 years of age with diabetes mellitus. The decision to treat should include a discussion of the benefits and risks between the patient and clinician. Based on moderate-quality evidence from nonrandomized trials, measuring fasting or nonfasting plasma lipid levels is effective in estimating ASCVD risk and documenting baseline LDL-C in adults 20 years and older who are not on lipid-lowering therapy. Contact Author disclosure: No relevant financial affiliations. Based on moderate-quality evidence from RCTs, the addition of nonstatin drug therapy should be considered at a threshold LDL-C level of at least 70 mg per dL on maximal statin therapy in patients with ASCVD at very high risk. Practice Guidelines: Cholesterol Management: ACC/AHA Updates Guideline. 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Finally, the ACC/AHA did not update the Pooled Cohort Equations risk assessment tool, despite widespread recognition that it can significantly overestimate 10-year risk of myocardial infarction and stroke. Given the imprecision in risk estimates, eliciting patients’ values and preferences regarding the potential benefits and harms of statins and other lipid-lowering agents remains essential to treatment decisions.—Kenny Lin, MD, MPH, AFP Deputy Editor, Guideline source: American College of Cardiology/American Heart Association, Systematic literature search described? A healthy lifestyle reduces ASCVD risk at all ages and can reduce the development of risk factors in younger patients. A healthy lifestyle … DOI: 10.1161/CIR.0000000000000625 CLINICAL STATEMENTS AND GUIDELINES remains ≥70 mg/dL (≥1.8 mmol/L) on maximally tolerated statin … • Maximally tolerated statin therapy is recommended for patients 20 to 75 years of age with an LDL-C level of 190 mg per dL or greater. Scope of Guideline. Based on moderate-quality evidence from nonrandomized trials, it is reasonable to obtain a coronary artery calcium (CAC) score for patients 40 to 75 years of age with an LDL-C level of 70 to 189 mg per dL and a 10-year ASCVD risk of 7.5% to 19.9% if a decision about statin therapy is uncertain. For example, the guideline recommends periodic lipid monitoring in patients receiving therapy, even though randomized trials generally prescribed fixed statin doses rather than titrating to LDL-C percentage reductions or threshold levels. 2019… 2. Copyright © 2020 American Academy of Family Physicians. This guideline addresses major issues related to cholesterol management and primary ASCVD prevention, which are also addressed in the recently published 2018 Cholesterol Clinical Practice Guidelines… FMX may have ended, but the learning doesn't stop! Also, it may be beneficial to treat patients 20 to 75 years of age who have an LDL-C level of 190 mg per dL or greater with ezetimibe if they have not been able to achieve a 50% reduction in LDL-C level while receiving maximally tolerated statin therapy and/or still have an LDL-C level of at least 100 mg per dL (2.59 mmol per L). Many recommendations were based on low quality or insufficient evidence such as those addressing specific target levels for treatment and the use of coronary artery calcium scoring for decision-making. These recommendations are only one element in the complex process of improving the health of America. If the CAC score is 100 or greater or in the 75th percentile or greater, statin therapy is indicated for any patient unless otherwise deferred by the outcome of the physician–patient risk discussion. 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