What are the management options for individuals at risk of Atherosclerotic Cardiovascular Disease (ASCVD)?

Management Options for Individuals at Risk of Atherosclerotic Cardiovascular Disease (ASCVD)

Comprehensive lifestyle modifications and statin therapy are the cornerstone interventions for managing individuals at risk of ASCVD, with specific pharmacological approaches determined by risk stratification.

Risk Assessment and Stratification

• Assess 10-year ASCVD risk using the Pooled Cohort Equations for adults 40-75 years without clinical ASCVD or diabetes who have LDL-C 70-189 mg/dL 1
• For individuals with diabetes, use risk calculators to better stratify ASCVD risk and guide therapy intensity 1
• Consider additional risk-enhancing factors including:
  • Primary LDL-C ≥160 mg/dL or genetic hyperlipidemias
  • Family history of premature ASCVD (onset <55 years in male first-degree relatives or <65 years in female first-degree relatives)
  • High-sensitivity C-reactive protein ≥2 mg/L
  • Coronary artery calcium score ≥300 Agatston units or ≥75th percentile for age/sex/ethnicity
  • Ankle-brachial index <0.9
  • Chronic inflammatory disorders (e.g., rheumatoid arthritis, systemic lupus erythematosus, psoriasis)
  • HIV infection 1

Primary Prevention Strategies

Lifestyle Modifications (Foundation for All Patients)

• Implement Mediterranean or DASH eating patterns 1
• Reduce saturated and trans fat intake 1
• Increase dietary n-3 fatty acids, viscous fiber, and plant stanols/sterols 1
• Increase physical activity 1
• Weight loss for individuals with overweight/obesity 1
• Smoking cessation 1

Pharmacological Therapy Based on Risk Categories

1. Individuals with LDL-C ≥190 mg/dL (ages ≥21)

   • High-intensity statin therapy without calculating 10-year ASCVD risk 1
   • Target at least 50% reduction in LDL-C 1
   • Consider adding ezetimibe if LDL-C remains ≥100 mg/dL 1

2. Individuals with Diabetes (ages 40-75) and LDL-C 70-189 mg/dL

   • Moderate-intensity statin therapy without calculating 10-year ASCVD risk 1
   • Consider high-intensity statin for those with multiple risk factors or 10-year ASCVD risk ≥7.5% 1

3. Individuals without Diabetes (ages 40-75) and LDL-C 70-189 mg/dL

   • 10-year ASCVD risk ≥7.5%: Moderate- or high-intensity statin therapy 1
   • 10-year ASCVD risk 5% to <7.5%: Consider moderate-intensity statin therapy 1
   • 10-year ASCVD risk <5%: Emphasize lifestyle modifications; selected individuals may benefit from statin therapy 1

4. Individuals with Chronic Inflammatory Disorders or HIV

   • For those with 10-year ASCVD risk ≥7.5%, consider moderate- to high-intensity statin therapy 1
   • Monitor lipid values 2-4 months after inflammatory disease control 1

Secondary Prevention Strategies (Established ASCVD)

• Ages ≤75 without safety concerns: High-intensity statin therapy 1
• Ages >75 or with safety concerns: Moderate-intensity statin therapy 1
• If LDL-C remains ≥70 mg/dL on maximally tolerated statin therapy, consider adding:
  • Ezetimibe (preferred due to lower cost) 1
  • PCSK9 inhibitor for very high-risk patients 1

Special Considerations

• Hypertension Management:

  • For individuals with diabetes and hypertension at higher cardiovascular risk: target BP <130/80 mmHg 1
  • For individuals with diabetes and hypertension at lower cardiovascular risk: target BP <140/90 mmHg 1
  • Use ACE inhibitors or ARBs as first-line therapy, especially with albuminuria or kidney disease 1

• Monitoring:

  • Obtain lipid profile at statin initiation, 4-12 weeks after starting or changing dose, and annually thereafter 1
  • Monitor for statin side effects and adjust intensity based on individual response 1
  • For those not on lipid-lowering therapy, obtain lipid profile at initial evaluation and every 5 years if under age 40, or more frequently if indicated 1

Common Pitfalls and Caveats

• Statin therapy is contraindicated during pregnancy 1
• For patients intolerant to statins, consider bempedoic acid as an alternative cholesterol-lowering therapy 1
• The absolute reduction in ASCVD events with statin therapy is proportional to baseline absolute ASCVD risk 1
• Avoid combination of ACE inhibitors and ARBs due to increased risk of hyperkalemia, syncope, and acute kidney injury 1
• For patients with resistant hypertension, consider adding mineralocorticoid receptor antagonists after excluding medication nonadherence and secondary hypertension 1