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

Management of Atherosclerotic Cardiovascular Disease (ASCVD)

All patients with established ASCVD require high-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily) if ≤75 years old, with moderate-intensity statins for those >75 years or with safety concerns. 1, 2

Pharmacologic Management

Lipid-Lowering Therapy

Statin Therapy:

• High-intensity statin (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) is mandatory for all ASCVD patients ≤75 years without contraindications 1, 2
• Moderate-intensity statin for patients >75 years after evaluating benefits, adverse effects, drug interactions, frailty, and patient preferences 2
• If high-intensity statin is not tolerated, use moderate-intensity statin 2

Intensification for Very High-Risk Patients:

• Very high-risk is defined as multiple major ASCVD events OR one major ASCVD event plus multiple high-risk conditions 2
• If LDL-C remains ≥70 mg/dL on maximally tolerated statin, add ezetimibe 10 mg daily 1, 2
• If LDL-C still ≥70 mg/dL or non-HDL-C ≥100 mg/dL on statin plus ezetimibe, add PCSK9 inhibitor (evolocumab, alirocumab, or inclisiran) 1, 2
• Target LDL-C <55 mg/dL for very high-risk patients 1

Blood Pressure Management

• Target blood pressure <130/80 mm Hg for all ASCVD patients 1
• Consider ACE inhibitor or angiotensin receptor blocker to reduce cardiovascular events 1
• For select patients without diabetes, intensive SBP target <120 mm Hg may provide additional benefit if tolerated 1

Antithrombotic Therapy

• Low-dose aspirin (75-100 mg daily) is standard for secondary prevention 1, 3
• For patients with recent acute coronary syndrome (ACS), dual antiplatelet therapy (aspirin plus P2Y12 inhibitor) for at least 1 year 1
  • Clopidogrel, ticagrelor, or prasugrel if percutaneous coronary intervention was performed 1
  • Clopidogrel or ticagrelor if no intervention 1
• For patients 1-3 years post-MI, adding ticagrelor to aspirin reduces recurrent ischemic events 1

Additional Pharmacotherapy

• Beta-blockers should be continued for at least 2 years after myocardial infarction 1
• Metformin is first-line for diabetes management if eGFR >30 mL/min, followed by SGLT2 inhibitor or GLP-1 receptor agonist 1
• For diabetes with CKD and eGFR ≥20 mL/min, SGLT2 inhibitor is recommended 1

Lifestyle Modifications

Dietary Interventions:

• Emphasize vegetables, fruits, nuts, whole grains, lean protein, and fish 1
• Minimize trans fats, processed meats, refined carbohydrates, and sweetened beverages 1
• For overweight/obesity, implement caloric restriction for weight loss 1

Physical Activity:

• 150 minutes per week of moderate-intensity activity OR 75 minutes per week of vigorous-intensity activity 1

Tobacco Cessation:

• Assess tobacco use at every visit 1
• Strongly advise cessation and provide assistance using the 5 A's approach (Ask, Advise, Assess, Assist, Arrange) 1
• Consider pharmacotherapy: nicotine replacement, bupropion, or varenicline 1

Monitoring and Follow-Up

• Reassess lipid panel 4-6 weeks after statin initiation or dose adjustment 4
• Target LDL-C reduction of ≥30-50% from baseline with moderate-intensity statins, ≥50% with high-intensity statins 1, 4
• Monitor for statin-associated muscle symptoms and educate patients to report unexplained muscle pain, tenderness, or weakness 4, 2
• Follow-up at 3 months once LDL-C goal achieved 1

Special Populations

Chronic Kidney Disease:

• Use moderate-intensity statins rather than high-intensity if eGFR <60 mL/min/1.73 m² 2
• Avoid metformin if eGFR <30 mL/min 1

Heart Failure:

• For ischemic heart failure with reduced ejection fraction, consider moderate-intensity statin if reasonable life expectancy (3-5 years) 2
• Avoid metformin in unstable or hospitalized heart failure patients 1

Diabetes Management:

• Statin therapy (moderate-intensity for primary prevention, high-intensity for ASCVD) is mandatory 1
• Lifestyle changes are crucial alongside pharmacotherapy 1

Common Pitfalls to Avoid

• Do not confuse statin-related symptoms with true statin intolerance; most muscle symptoms occur without CK elevation >3× ULN 5
• Do not skip ezetimibe before considering PCSK9 inhibitors; follow stepwise approach: maximally tolerated statin → add ezetimibe → consider PCSK9 inhibitor 5
• Do not use aspirin for primary prevention in low-risk patients due to lack of net benefit 1
• Do not discontinue beta-blockers prematurely after MI; continue for at least 2 years 1
• Monitor for drug-drug interactions, particularly in older patients on multiple medications 2