What is the American Heart Association (AHA) protocol for treating dyslipidemia?

AHA/ACC Protocol for Dyslipidemia Treatment

The 2018 AHA/ACC guideline prioritizes fixed-dose statin therapy based on four specific benefit groups rather than treating to LDL-C targets, with heart-healthy lifestyle modifications serving as the foundation for all patients. 1

Core Treatment Framework

Foundation: Lifestyle Modification First

• Heart-healthy lifestyle is mandatory across all age groups and risk categories before and during drug therapy, including adherence to a low saturated fat diet, regular exercise, tobacco avoidance, and healthy weight maintenance 1
• Lifestyle therapy is the primary intervention for metabolic syndrome specifically 1
• In young adults (20-39 years), assess lifetime risk to facilitate clinician-patient discussion and emphasize intensive lifestyle efforts 1

Four Statin Benefit Groups (Who Gets Treated)

1. Clinical ASCVD (Secondary Prevention)

• Use high-intensity statin therapy or maximally tolerated statin to reduce LDL-C by ≥50% 1
• Goal is maximum LDL-C reduction on statin therapy—the greater the reduction, the greater the subsequent risk reduction 1

2. Severe Primary Hypercholesterolemia

• LDL-C ≥190 mg/dL (≥4.9 mmol/L): Begin high-intensity statin immediately without calculating 10-year risk 1
• If LDL-C remains ≥100 mg/dL (≥2.6 mmol/L) on statin, adding ezetimibe is reasonable 1

3. Diabetes Mellitus (Ages 40-75)

• Patients with diabetes and LDL-C 70-189 mg/dL should receive at least moderate-intensity statin therapy 1
• Consider high-intensity statin if multiple ASCVD risk factors present 1

4. Primary Prevention Based on Risk Score

• For LDL-C 70-189 mg/dL, calculate 10-year ASCVD risk using Pooled Cohort Equations 1
• If 10-year risk ≥7.5%, engage in clinician-patient risk discussion before initiating statin 1
• This discussion must address lifestyle optimization, potential benefits versus adverse effects, drug interactions, and patient preference 1

Adding Non-Statin Therapy

Very High-Risk ASCVD Patients Only

Very high-risk is defined as: history of multiple major ASCVD events OR one major ASCVD event plus multiple high-risk conditions 1

Sequential approach when LDL-C remains ≥70 mg/dL (≥1.8 mmol/L) on maximally tolerated statin: 1

1. First, add ezetimibe (reasonable option)
2. Second, add PCSK9 inhibitor only if LDL-C still ≥70 mg/dL on statin plus ezetimibe (reasonable but cost-effectiveness is low and long-term safety >3 years uncertain as of guideline publication)

Critical Distinction from Other Guidelines

• The AHA/ACC does NOT recommend routine LDL-C targets for most patients—instead uses fixed-dose statin intensity 1
• Non-statin therapies are reserved for select high-risk groups only, unlike European guidelines which are more liberal with non-statin use 1
• Cost-value considerations are explicitly incorporated into AHA/ACC recommendations 1

Statin Intensity Definitions

High-intensity statins (reduce LDL-C by ≥50%): 1

• Atorvastatin 40-80 mg daily
• Rosuvastatin 20-40 mg daily

Moderate-intensity statins (reduce LDL-C by 30-49%): 1

• Atorvastatin 10-20 mg daily
• Rosuvastatin 5-10 mg daily
• Simvastatin 20-40 mg daily
• Pravastatin 40-80 mg daily
• Lovastatin 40 mg daily
• Fluvastatin 80 mg daily
• Pitavastatin 2-4 mg daily

Populations Where Statins Show NO Benefit

Do not initiate statin therapy in: 1

• NYHA Class II-IV heart failure patients
• Patients receiving maintenance hemodialysis

Risk Assessment Tool

• Use the Pooled Cohort Equations to estimate 10-year ASCVD risk in white and black men and women for primary prevention decisions 1
• This tool more accurately identifies higher-risk individuals who will benefit from statin therapy 1

Safety Monitoring

• Assess for statin-associated muscle symptoms and provide expert guidance on management 1
• Use randomized controlled trial data to understand net benefit versus adverse effects 1
• For statin-intolerant patients, use the highest tolerable statin dose 1

Key Philosophical Shift

The 2013/2018 guidelines represent a fundamental departure from previous approaches by eliminating treat-to-target strategies in favor of evidence-based fixed-dose statin therapy for defined benefit groups 1. This reflects that randomized trials compared fixed statin doses rather than titrated therapy to achieve specific LDL-C goals 1.