Atherosclerotic cardiovascular
disease (ASCVD) is a major cause of morbidity and mortality. An acute cardiac
event can be prevented by effective management of risk factors including
dyslipidemia, which is a major risk factor for initiation and progression of
the atherosclerotic process and thereby to cardiovascular events. Hence,
managing the dyslipidemia-related cardiovascular
risk in these patients is important for secondary prevention of CAD.
Major professional cardiology
and endocrinology associations have issued guidelines on management of
dyslipidemia, which differ in their approaches in managing lipids in these
patients regarding assessment of risk, lipid goals and targets and
pharmacological treatment.
Latest in this list of
guidelines on management of dyslipidemia are recommendations from the American
Association of Clinical Endocrinologists and American College of Endocrinology
(AACE/ACE) released in 2017. These guidelines have for the first time defined
an “extreme” cardiovascular risk category and also bring back the concept of
‘target’-based lipid management.
The AHA/ACC guidelines issued
in 2013 had recommended “appropriate intensity” of statin therapy for the four
groups of primary- and secondary-prevention patients instead of treating
dyslipidemia to specific ‘targets’. Hence, these guidelines removed specific
targets or goals for LDL- or non-HDL-cholesterol … a change from the ATP III
recommendations in 2001, which advised determination of risk category and set
goals according to the risk category.
The 2017 AACE/ACE guidelines
have categorized patients into five atherosclerotic cardiovascular disease
(ASCVD) risk categories – low risk, moderate risk, high risk, very high and
extreme risk - and now recommend lipid goals for all the five categories.
· Low risk: Individuals with no risk
factors: LDL < 130 mg/dL, non-HDL < 160 mg/dL, apoB not relevant
is recommended.
· Moderate risk: Individuals with 2 or fewer
risk factors and a calculated 10-year risk < 10%: LDL < 100 mg/dL,
non-HDL < 130 mg/dL, apoB < 90 mg/dL is recommended.
· High risk: Individuals with an ASCVD
equivalent including diabetes or stage 3/4 CKD with no other risk factors, or
individuals with ≥2 risk factors and a 10-year risk of 10%- 20%: LDL <
100 mg/dL, non-HDL < 130 mg/dL, apoB < 90 mg/dL is recommended.
· Very high risk: Individuals with established
or recent hospitalization for acute coronary syndrome (ACS); coronary, carotid
or peripheral vascular disease; diabetes or stage 3/4 CKD with ≥1 risk factors;
a calculated 10-year risk > 20%; or heterozygous familial
hypercholesterolemia [HeFH]): LDL < 70 mg/dL, non-HDL < 80 mg/dL, apoB
< 80 mg/dL is recommended.
· Extreme risk: Individuals with progressive
ASCVD, including unstable angina that persists after achieving an LDL <70 or
established clinical ASCVD in individuals with diabetes, stage 3/4 CKD, and/or
HeFH, or in individuals with a history of premature ASCVD (males <55 years;
females <65 years): LDL < 55 mg/dL, non-HDL < 80 mg/dL, apolipoprotein
B (apoB) < 70 mg/dL is recommended.
Lowering cholesterol is
important for all age groups, both men and women, regardless of the presence of
absence of heart disease. A 1% rise in cholesterol level can raise the chances
of heart attack by 2%. 1% reduction of “good” HDL cholesterol increases the
chances of suffering from a heart attack by 3%.
However, it is important to
keep in mind that every patient is different; hence, treatment, including lipid
goals should be individualized according to that particular
patient.
Dr
KK Aggarwal
Padma
Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications
President
Heart Care Foundation of India
Immediate
Past National President IMA
