What is the recommended management for patients with Atherosclerotic Cardiovascular Disease (ASCVD)?

Management of Atherosclerotic Cardiovascular Disease (ASCVD)

For patients with established ASCVD, initiate high-intensity statin therapy immediately (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily) if age ≤75 years, or moderate-intensity statin if >75 years, combined with comprehensive lifestyle modification, blood pressure control to <130/80 mmHg, antiplatelet therapy, and smoking cessation. 1, 2

Lipid Management: The Foundation of ASCVD Treatment

Statin Therapy by Age and Risk

• Age ≤75 years: High-intensity statin therapy is the standard of care (Class I recommendation), targeting at least 50% LDL-C reduction 1, 2

  • Atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily 2, 3
  • If high-intensity statin is not tolerated, use moderate-intensity statin 2

• Age >75 years: Moderate- or high-intensity statin is reasonable after evaluating benefits, adverse effects, drug interactions, frailty, and patient preferences (Class IIa recommendation) 2

Intensification for Very High-Risk Patients

Very high-risk is defined as multiple major ASCVD events (≥2) OR one major ASCVD event plus multiple high-risk conditions 1, 2

The stepwise intensification algorithm: 1, 2

1. Step 1: Maximize statin therapy (high-intensity if tolerated)
2. Step 2: If LDL-C ≥70 mg/dL on maximally tolerated statin, add ezetimibe 10 mg daily (Class IIa recommendation) 1, 2
3. Step 3: If LDL-C remains ≥70 mg/dL or non-HDL-C ≥100 mg/dL on maximal statin plus ezetimibe, add PCSK9 inhibitor (Class IIa recommendation) 1, 2

• Target LDL-C: <55 mg/dL for very high-risk patients 1
• Monitoring: Reassess lipids at 4-6 weeks after each therapy adjustment 1, 4

Fixed-Dose Combinations

Use fixed-dose combination therapies preferentially (statin + ezetimibe) to increase both the number of patients reaching LDL-C goals and adherence to therapy 1

Blood Pressure Management

• Target: <130/80 mmHg for all patients with clinical cardiovascular disease 1
• Nonpharmacological interventions are recommended for all adults with elevated blood pressure 1
• For select patients without diabetes and not undergoing surgical aortic repair, intensive SBP goal of <120 mmHg may provide added benefit if tolerated 1

Antiplatelet Therapy

Secondary Prevention After Acute Coronary Syndrome

• Dual antiplatelet therapy (P2Y12 receptor antagonist + aspirin) should be used for at least 1 year in patients who have had an ACS 1

  • If no percutaneous coronary intervention: clopidogrel or ticagrelor 1
  • If percutaneous coronary intervention performed: clopidogrel, ticagrelor, or prasugrel 1

• In patients with diabetes and prior MI (1-3 years before), adding ticagrelor to aspirin significantly reduced recurrent ischemic events 1

Chronic Stable ASCVD

• Low-dose aspirin for patients with concomitant atheroma and/or penetrating aortic ulceration (Class IIb recommendation) 1

Additional Pharmacologic Interventions

ACE Inhibitors or ARBs

• Consider ACE inhibitor or angiotensin receptor blocker therapy in patients with known ASCVD to reduce cardiovascular events (Class B recommendation) 1

Beta-Blockers

• In patients with prior myocardial infarction, beta-blockers should be continued for at least 2 years after the event (Class B recommendation) 1

Diabetes Management in ASCVD

For patients with type 2 diabetes and established ASCVD: 1

• First-line: Lifestyle management and metformin (if eGFR ≥30 mL/min/1.73 m²) 1
• Add: SGLT2 inhibitor (if eGFR ≥20 mL/min/1.73 m²) OR GLP-1 receptor agonist with demonstrated cardiovascular benefit (Class A recommendation) 1
• These agents reduce major adverse cardiovascular events and cardiovascular mortality beyond glucose control 1

Lifestyle Modifications: Non-Negotiable Foundation

Dietary Interventions

All adults with ASCVD should consume a heart-healthy diet that: 1, 5

• Emphasizes: vegetables, fruits, nuts, whole grains, lean vegetable or animal protein, fish
• Minimizes: trans fats, processed meats, refined carbohydrates, sweetened beverages
• Reduces: cholesterol-raising fatty acids and dietary cholesterol 5
• Increases: unsaturated fatty acids, plant proteins, viscous fibers 5

Physical Activity

• Engage in at least 150 minutes per week of moderate-intensity physical activity OR 75 minutes per week of vigorous-intensity physical activity 1

Weight Management

• For adults with overweight and obesity, counseling and caloric restriction are recommended for achieving and maintaining weight loss 1

Smoking Cessation

• Critical: All adults should be assessed at every healthcare visit for tobacco use 1
• Those who use tobacco should be assisted and strongly advised to quit using the 5 A's approach (Ask, Advise, Assess, Assist, Arrange) 1
• Effective strategies include dedicated multidisciplinary programs, app-based tools, or pharmacotherapy with nicotine replacement, bupropion, varenicline, or combination 1
• Cigarette smoking is the largest modifiable risk factor for ASCVD progression 1

Special Populations

Chronic Kidney Disease

• Use moderate-intensity statins rather than high-intensity in patients with eGFR <60 mL/min/1.73 m² 2
• Metformin can be used if eGFR ≥30 mL/min/1.73 m² but should be avoided in unstable patients 1
• Adjust metformin dose when eGFR <45 mL/min/1.73 m² 1

Heart Failure

• For patients with heart failure with reduced ejection fraction due to ischemic heart disease, consider moderate-intensity statin if reasonable life expectancy (3-5 years) and not already on statin for ASCVD (Class IIb recommendation) 2
• Metformin may be used in stable congestive heart failure if eGFR >30 mL/min but should be avoided in unstable or hospitalized patients 1

Common Pitfalls to Avoid

Statin Intolerance Misdiagnosis

• Do not confuse statin-related symptoms with policy-defined statin intolerance 6
• True statin intolerance requires statin-associated muscle symptoms with CK elevation >3 times ULN or CK elevation ≥10 times ULN 6
• Many patients experience muscle symptoms on statins without meeting CK elevation thresholds required for PCSK9 inhibitor approval 6
• Before considering non-statin therapy, trial alternative statins at varying intensities (rosuvastatin 5-10 mg, atorvastatin 10-20 mg, or fluvastatin) 6

Premature Escalation to Advanced Therapies

• Follow the stepwise approach: maximize statin → add ezetimibe → consider PCSK9 inhibitor only if targets remain unmet 1, 6
• Do not skip ezetimibe as first-line non-statin therapy 6

Drug-Drug Interactions

• Evaluate for potential drug-drug interactions, particularly in older patients on multiple medications 2
• Monitor for statin-associated muscle symptoms (SAMS) 2

Team-Based Care and Patient Engagement

• A team-based care approach is an effective strategy for ASCVD prevention and management 1
• Evaluate social determinants of health that affect individuals to inform treatment decisions 1
• Shared decision-making between clinicians and patients enhances adherence to recommendations 1
• Use discharge letters to increase knowledge of physicians and patients on the need for long-term continuing optimal lipid-lowering therapy 1

Monitoring and Follow-Up

• Initial reassessment: Lipid panel at 4-6 weeks after statin initiation, targeting ≥30-50% LDL-C reduction from baseline 4
• Subsequent monitoring: Follow up at 3 months if LDL-C goal achieved 1
• If goal not achieved: Intensify lipid-lowering therapy and/or refer to lipid center 1
• Monitor for statin-related adverse effects (unexplained muscle pain, tenderness, or weakness) and educate patients to report these symptoms 4