What are the initial pharmacological interventions and lifestyle modifications for managing Atherosclerotic Cardiovascular Disease (ASCVD)?

Management of Atherosclerotic Cardiovascular Disease (ASCVD)

The initial management of ASCVD should include comprehensive lifestyle modifications (Mediterranean or DASH diet, increased physical activity, weight management, and smoking cessation) combined with statin therapy as the first-line pharmacological intervention, with intensity based on risk stratification. 1

Lifestyle Modifications

Dietary Recommendations

• Mediterranean or DASH eating pattern - emphasizing:
  • Vegetables, fruits, nuts, whole grains, lean protein sources
  • Increased plant stanols/sterols and n-3 fatty acids
  • Increased viscous fiber (oats, legumes, citrus)
  • Reduced saturated fat (<7% of calories) and trans fat
  • Reduced processed meats, refined carbohydrates, and sweetened beverages 1

Physical Activity

• Minimum 150 minutes per week of moderate-intensity activity or 75 minutes of vigorous-intensity activity 1
• Daily physical activity when possible, at least 3-4 times weekly
• Activities may include walking, jogging, cycling, or other aerobic activities 1

Weight Management

• Weight loss for individuals with overweight or obesity
• Caloric restriction as appropriate to achieve and maintain healthy weight 1

Smoking Cessation

• Complete cessation counseling for all tobacco users
• Pharmacological therapy (nicotine replacement, bupropion, varenicline)
• Formal smoking cessation programs as appropriate 1
• Avoidance of secondhand smoke

Pharmacological Management

Statin Therapy

• First-line pharmacological treatment for ASCVD 1, 2
• Intensity based on risk stratification:
  • High-intensity statin (reduces LDL-C by ≥50%) for patients aged 40-75 years at higher cardiovascular risk 1
  • Target LDL-C goal of <70 mg/dL for high-risk patients 1
  • For patients aged 20-39 years with additional ASCVD risk factors, consider initiating statin therapy 1

Additional Lipid-Lowering Therapy

• For patients not achieving LDL-C goals with maximally tolerated statins:
  • Ezetimibe as add-on therapy 1
  • PCSK9 inhibitors for those with multiple risk factors and LDL-C ≥70 mg/dL despite statin therapy 1
  • Bempedoic acid for statin-intolerant patients 1

Antihypertensive Therapy

• For patients with hypertension:
  • ACE inhibitors or ARBs as first-line therapy, especially with albuminuria 1
  • Thiazide-like diuretics or dihydropyridine calcium channel blockers as alternatives 1
  • β-blockers indicated only for patients with prior MI, active angina, or heart failure with reduced ejection fraction 1
  • Target blood pressure generally <130/80 mm Hg 1

Antithrombotic Therapy

• Low-dose aspirin may be considered in patients with atherosclerotic AAA with concomitant atheroma 1
• However, aspirin should be used infrequently in routine primary prevention due to lack of net benefit 1

Risk Assessment and Stratification

• 10-year ASCVD risk estimation for adults 40-75 years before starting pharmacological therapy 1
• Risk enhancers to consider:
  • Family history of premature ASCVD
  • Chronic inflammatory conditions
  • Metabolic syndrome
  • Chronic kidney disease
  • Elevated triglycerides
  • Coronary artery calcium score (for adults ≥40 years) 1

Common Pitfalls and Caveats

1. Therapeutic inertia - Failure to titrate or add medications in a timely fashion to achieve targets 1
2. Combination therapy risks - Avoid combining ACE inhibitors with ARBs due to increased adverse events (hyperkalemia, syncope, AKI) 1
3. Bedtime dosing - No proven benefit for preferential bedtime dosing of antihypertensive medications 1
4. Statin intolerance - Consider bempedoic acid as an alternative for statin-intolerant patients 1
5. Inadequate risk assessment - Traditional risk factors alone may be poor individual discriminators of CAD; consider imaging (e.g., coronary artery calcium) for better risk stratification in select patients 1

Special Populations

Diabetes Patients

• Optimize glycemic control, particularly for those with elevated triglycerides 1
• Consider GLP-1 receptor agonists or SGLT-2 inhibitors for patients with type 2 diabetes 1

Elderly Patients (>75 years)

• Continue statin therapy if already on treatment
• For statin-naïve patients, consider initiating moderate-intensity statin therapy after discussing benefits and risks 1

By implementing these comprehensive lifestyle modifications and appropriate pharmacological interventions based on individual risk assessment, the risk of ASCVD-related morbidity and mortality can be significantly reduced.