What are the American College of Cardiology (ACC)/American Heart Association (AHA) treatment guidelines for dyslipidemia?

From the Guidelines

The American College of Cardiology/American Heart Association (ACC/AHA) guidelines for dyslipidemia treatment prioritize atherosclerotic cardiovascular disease (ASCVD) risk reduction over targeting specific LDL-C levels, with statins as the cornerstone of therapy. The guidelines recommend statin therapy for four groups of patients: those with clinical ASCVD, primary elevations of LDL-C ≥190 mg/dl, individuals 40 to 75 years of age with diabetes and LDL-C 70 to 189 mg/dl, and individuals without clinical ASCVD or diabetes who are 40 to 75 years of age with LDL-C 70 to 189 mg/dl and an estimated 10-year ASCVD risk of ≥7.5% by the Pooled Risk Equations 1.

Key Recommendations

• High-intensity statins (atorvastatin 40-80mg or rosuvastatin 20-40mg daily) are recommended for patients with clinical ASCVD, LDL-C ≥190 mg/dL, diabetes with high risk, or 10-year ASCVD risk ≥7.5% 1.
• Moderate-intensity statins (atorvastatin 10-20mg, rosuvastatin 5-10mg, simvastatin 20-40mg, pravastatin 40-80mg daily) are appropriate for lower-risk individuals.
• Lifestyle modifications, including a heart-healthy diet, regular physical activity, weight management, and smoking cessation, remain fundamental 1.
• Treatment decisions should involve shared decision-making, considering individual preferences, potential benefits, risks, and costs.
• Regular monitoring of lipid levels and liver function tests is recommended to assess treatment efficacy and safety 1.

Statin Therapy

• The guidelines do not support dose titration to achieve optimal levels of LDL-C, non–HDL-C, or Apo B, as recommended in previous guidelines 1.
• Low-intensity statins are recommended only in patients who have experienced or are at risk for adverse effects of treatment 1.
• For patients not achieving sufficient LDL-C reduction or intolerant to statins, ezetimibe (10mg daily) is typically added first, followed by PCSK9 inhibitors (evolocumab 140mg every 2 weeks or alirocumab 75-150mg every 2 weeks) if needed.

Lifestyle Modifications

• A healthy lifestyle is the foundation for cardiovascular health, including a diet that is low in saturated fat, trans fat, and sodium; emphasizes vegetables, fruits, whole grains, low-fat dairy products, poultry, fish, legumes, nontropical vegetable oils, and nuts; and limits sweets, sugar-sweetened beverages, and red meats 1.
• Regular aerobic physical activity and maintenance of a healthy body weight are also recommended 1.

From the Research

American College of Cardiology/American Heart Association Treatment Guidelines for Dyslipidemia

• The treatment of lipid disorders begins with lifestyle therapy to improve nutrition, physical activity, weight, and other factors that affect lipids 2.
• Secondary causes of lipid disorders should be addressed, and pharmacologic therapy initiated based on a patient's risk for atherosclerotic cardiovascular disease (ASCVD) 2.

Risk-Based Treatment Approach

• Patients at extreme ASCVD risk should be treated with high-intensity statin therapy to achieve a goal low-density lipoprotein cholesterol (LDL-C) of <55 mg/dL 2.
• Those at very high ASCVD risk should be treated to achieve LDL-C <70 mg/dL 2.
• Treatment for moderate and high ASCVD risk patients may begin with a moderate-intensity statin to achieve an LDL-C <100 mg/dL, while the LDL-C goal is <130 mg/dL for those at low risk 2.

Additional Treatment Considerations

• Treatment should be intensified, including the addition of other LDL-C-lowering agents (i.e., proprotein convertase subtilisin/kexin type 9 inhibitors, ezetimibe, colesevelam, or bempedoic acid) as needed to achieve treatment goals 2.
• When targeting triglyceride levels, the desirable goal is <150 mg/dL 2.
• Statin therapy should be combined with a fibrate, prescription-grade omega-3 fatty acid, and/or niacin to reduce triglycerides in all patients with triglycerides ≥500 mg/dL 2.

Patient-Centered Management

• The National Lipid Association recommendations emphasize the importance of patient-centered management of dyslipidemia, including lifestyle therapies and consideration of special populations such as children and adolescents, women, and older patients 3.
• Strategies to improve patient outcomes by increasing adherence and using team-based collaborative care are also recommended 3.