What are the management options for Atherosclerotic Cardiovascular Disease (ASVD)?

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) targeting at least 50% LDL-C reduction, and add ezetimibe if LDL-C remains ≥70 mg/dL on maximally tolerated statin therapy. 1, 2

Risk Stratification and Treatment Intensity

Very High-Risk ASCVD Patients

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

• Target LDL-C <70 mg/dL (ideally <55 mg/dL) using maximally tolerated statin therapy. 1, 3
• Add ezetimibe when LDL-C remains ≥70 mg/dL despite maximally tolerated statin. 1, 2
• Consider PCSK9 inhibitor if LDL-C remains ≥70 mg/dL on statin plus ezetimibe, though long-term safety beyond 3 years is uncertain and cost-effectiveness is low. 1
• High-intensity statins reduce LDL-C by approximately 50%, while ezetimibe adds an additional 20-25% reduction. 3

Standard ASCVD Patients

• Use high-intensity statin for patients ≤75 years without safety concerns. 2
• Use moderate-intensity statin for patients >75 years or those with safety concerns. 2
• Target at least 50% LDL-C reduction from baseline. 1

Comprehensive Lifestyle Management

Smoking Cessation (Highest Priority)

• All patients must achieve complete cessation and abstinence from smoking of any kind—this is non-negotiable. 1
• Offer structural follow-up support including nicotine replacement therapy, varenicline, and bupropion, individually or in combination. 1
• E-cigarettes may be considered as a brief aid to quit tobacco smoking, but avoid simultaneous use with conventional cigarettes. 1
• Avoid exposure to secondhand smoke and air pollution. 1

Dietary Modifications

• Implement Mediterranean diet pattern emphasizing vegetables, fruits, nuts, whole grains, legumes, lean protein, and fatty fish. 1
• Minimize intake of trans fats, processed meats, refined carbohydrates, and sweetened beverages. 1
• Reduce saturated fat and dietary cholesterol intake. 4, 5
• Add dietary adjuncts: viscous fiber, plant sterols/stanols (2 grams daily), which can reduce LDL-C by additional 5-10%. 4
• Referral to registered dietitian nutritionist is strongly recommended for medical nutrition therapy. 1, 4

Physical Activity

• Engage in at least 150 minutes per week of moderate-intensity aerobic activity OR 75 minutes per week of vigorous-intensity activity. 1
• For patients with peripheral arterial disease, low- to moderate-intensity aerobic activities increase overall and pain-free walking distance. 1

Weight Management

• For patients with overweight and obesity (BMI >25), implement counseling and caloric restriction to achieve and maintain weight loss. 1, 3

Blood Pressure Management

• Target blood pressure <130/80 mmHg for all ASCVD patients. 1, 3
• Begin with nonpharmacological interventions (reduced sodium intake, DASH diet, physical activity, weight reduction). 1, 3
• For stage 2 hypertension, add second antihypertensive agent (calcium channel blocker or thiazide diuretic). 3
• Use ACE inhibitors or ARBs as first-line therapy, especially with albuminuria or kidney disease. 2
• Avoid beta-blockers unless specifically indicated, as they can worsen insulin sensitivity and lipid profiles. 3

Diabetes Management

• For patients with type 2 diabetes, metformin is first-line therapy after lifestyle modifications. 1
• Consider adding SGLT2 inhibitor or GLP-1 receptor agonist for additional cardiovascular benefit. 1
• Target blood pressure <130/80 mmHg for those at higher cardiovascular risk. 2

Antiplatelet Therapy

• Aspirin is NOT recommended for routine primary prevention of ASCVD due to lack of net benefit. 1
• For secondary prevention in established ASCVD, aspirin therapy should be considered based on individual bleeding risk assessment. 2

Special Populations

Severe Primary Hypercholesterolemia (LDL-C ≥190 mg/dL)

• Begin high-intensity statin therapy without calculating 10-year ASCVD risk. 1
• If LDL-C remains ≥100 mg/dL, add ezetimibe. 1
• If LDL-C remains ≥100 mg/dL on statin plus ezetimibe with multiple risk-enhancing factors, consider PCSK9 inhibitor. 1

Pregnancy

• Discontinue all lipid-lowering therapy (statins, ezetimibe) due to potential fetal harm. 1
• Implement intensive lifestyle modifications and monitor for significant LDL-C elevations. 1
• Bile acid sequestrants may be used if necessary, but monitor for vitamin K deficiency. 1
• Resume statin and ezetimibe therapy after completion of breastfeeding. 1

Monitoring and Follow-Up

• 4-week visit: Assess blood pressure, medication adherence, and side effects. 3
• 6-week visit: Recheck lipid panel to assess treatment response. 3
• 3-month visit: Reassess blood pressure and lipid targets; intensify therapy if goals not met. 3
• Monitor for statin intolerance; if present, consider alternative agents or referral to lipid specialist. 1, 2

Critical Pitfalls to Avoid

• Therapeutic inertia is the most common failure—only 20% of high-risk patients reach LDL-C goals with current practice patterns. 3, 6
• Using LDL-C <100 mg/dL as a target leaves patients at substantial residual risk; aim for <70 mg/dL (or <55 mg/dL in very high-risk). 3
• Prescribing low-intensity statins is inadequate for ASCVD patients—always use high-intensity unless contraindicated. 3
• Delaying addition of ezetimibe when LDL-C targets are not met on statin monotherapy. 3
• Failing to address all modifiable risk factors simultaneously (lipids, blood pressure, smoking, diabetes, lifestyle). 7, 8