What is the typical treatment for Atherosclerotic Cardiovascular Disease (ASCVD)?

Treatment of Atherosclerotic Cardiovascular Disease (ASCVD)

For patients with established ASCVD, initiate high-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily) if age ≤75 years with no safety concerns, or moderate-intensity statin therapy if age >75 years or safety concerns exist. 1

Foundation: Lifestyle Modifications

All ASCVD patients must implement comprehensive lifestyle changes as the foundation of treatment, regardless of pharmacological therapy 1:

• Diet: Heart-healthy diet emphasizing vegetables, fruits, nuts, whole grains, lean protein, and fish while minimizing trans fats, processed meats, refined carbohydrates, and sweetened beverages 1
• Physical Activity: Minimum 150 minutes per week of moderate-intensity or 75 minutes per week of vigorous-intensity exercise 1
• Smoking Cessation: Complete tobacco avoidance with counseling and pharmacotherapy (nicotine replacement, varenicline, or bupropion) as needed 1, 2
• Weight Management: Achieve and maintain healthy weight through caloric restriction if overweight or obese 1

Primary Pharmacological Treatment: Statin Therapy

Statin Intensity Selection

For patients with clinical ASCVD (defined as acute coronary syndromes, history of MI, stable/unstable angina, coronary or arterial revascularization, stroke, TIA, or peripheral arterial disease) 1:

• Age ≤75 years without safety concerns: High-intensity statin (Class I, Level A) 1

  • Atorvastatin 40-80 mg daily OR rosuvastatin 20-40 mg daily 2, 3
  • Target: ≥50% LDL-C reduction 1, 3

• Age >75 years OR safety concerns present: Moderate-intensity statin (Class I, Level A) 1

  • Target: 30-49% LDL-C reduction 2, 3

Monitoring

• Obtain lipid panel 4-12 weeks after initiating statin therapy to assess response 2
• Monitor liver enzymes, creatine kinase, glucose, and creatinine before starting therapy and as clinically indicated 1, 4

Additional Lipid-Lowering Therapy

Second-Line: Ezetimibe

Add ezetimibe 10 mg daily to maximally tolerated statin therapy when LDL-C goals are not achieved 3, 5:

• Provides additional 20-25% LDL-C reduction 3, 5
• Well-tolerated with minimal adverse effects 5

Third-Line: PCSK9 Inhibitors

Consider PCSK9 inhibitors (evolocumab or alirocumab) for very high-risk patients with persistently elevated LDL-C despite maximal statin plus ezetimibe therapy 3, 5:

• Provides additional 60% LDL-C reduction 3
• Target LDL-C <55 mg/dL (<1.4 mmol/L) for very high-risk patients 5

Antiplatelet Therapy

Clopidogrel 75 mg daily is indicated for secondary prevention in ASCVD patients 6:

• Demonstrated 8.7% relative risk reduction versus aspirin in patients with recent MI, recent stroke, or peripheral arterial disease (p=0.045) 6
• Most effective in peripheral arterial disease subgroup 6
• Continue indefinitely unless contraindicated; do not discontinue without discussing with prescribing physician 6

Important caveat: Avoid concurrent use of omeprazole or esomeprazole with clopidogrel, as these significantly reduce antiplatelet activity 6

Blood Pressure Management

Target blood pressure <130/80 mmHg for all ASCVD patients 1, 2:

• Initiate appropriate antihypertensive therapy based on current guidelines 2
• Regular monitoring essential to ensure adequate control 2

Diabetes Management (if present)

For ASCVD patients with type 2 diabetes 1:

• Lifestyle changes remain crucial 1
• Metformin as first-line pharmacotherapy 1
• Consider SGLT2 inhibitor or GLP-1 receptor agonist for cardioprotective effects 1, 3
• Hypertriglyceridemia (≥175 mg/dL) favors intensification of statin therapy 2

Additional Considerations

Renin-Angiotensin-Aldosterone System Inhibitors

Consider ACE inhibitors or ARBs for additional cardiovascular protection, particularly in patients with hypertension, diabetes, or heart failure 7

Beta-Blockers

Indicated for patients with history of MI or heart failure 7

Vaccinations

Ensure up-to-date influenza and pneumococcal vaccinations to reduce infection-related cardiovascular events 7

Common Pitfalls to Avoid

• Do not titrate statins to specific LDL-C targets—use appropriate intensity statin therapy based on risk category, as RCT evidence does not support treat-to-target strategies 1
• Do not add niacin or fibrates to achieve non-HDL-C targets once LDL-C goals are met—no evidence of additional ASCVD outcome reduction 1
• Do not delay statin therapy in favor of supplements or less effective alternatives—this increases cardiovascular risk 5
• Avoid routine aspirin plus clopidogrel in stable ASCVD without specific indication—the CHARISMA trial showed no benefit and increased bleeding risk 6
• Do not use statins in patients with NYHA Class II-IV heart failure or those on maintenance hemodialysis—no ASCVD event reduction demonstrated 1