By Martta Kelly

Treatment for elevated blood lipid levels should begin much earlier and more aggressively to reduce the risk for atherosclerotic cardiovascular disease (ASCVD), according to an updated comprehensive guideline.

The guideline, developed by the American College of Cardiology (ACC), the American Heart Association (AHA), and nine other top medical associations, was jointly published.

In the guideline, the authors now endorse use of the AHA’s new cardiovascular disease calculator, Predicting Risk of Cardiovascular Disease EVENTs (PREVENT), for the primary prevention of ASCVD.

The PREVENT-ASCVD equations were derived from a database of more than 3 million US adults and received external validation from an additional independent group of individuals of the same number, said Carl E. Orringer, MD, member of the AHA/ACC writing committee and director of preventive cardiology at Naples Comprehensive Health Care System in Naples, Florida.

Rather than utilizing older datasets alone, the PREVENT model uses large-scale, contemporary, and diverse observational data sources, according to the AHA.

With the goal of catching cardiac disease earlier, the age of risk assessment was expanded to include people aged 30-79 years, up from 40 to 75 years, Orringer said.

“In addition to traditional risk factors, other variables were added that may further enhance risk prediction, such as hemoglobin A1c, urinary/creatinine ratio, and ZIP code,” Orringer said. “The calculator also considers the importance of social determinants of health in determining risk.”

PREVENT was designed to help patients understand their risk for ASCVD over a 10- or 30-year period. The updated guideline now recommends lipid-lowering therapy for those who have a 10-year risk of 5%, according to co-developer of the PREVENT calculator Sadiya S. Khan, MD, MSc, Magerstadt Professor of Cardiovascular Epidemiology at Northwestern University Feinberg School of Medicine in Chicago.

More than a quarter of US adults have elevated levels of low-density lipoprotein cholesterol (LDL-C), according to the AHA. However, although about 80% of cardiovascular disease is preventable, the authors noted only 54.5% of people who might benefit from cholesterol-lowering medication are taking it. Many are unaware of their condition until they visit a physician.

Testing and Targets

Guideline experts recommend an LDL-C target of < 100 mg/dL to prevent a first heart attack or stroke and a target of < 70 mg/dL for people at high risk. For those with ASCVD who are at extremely high risk for cardiac events, the LDL-C goal should be < 55 mg/dL. Key risk factors include diabetes, HIV, and kidney disease, Khan said.

Having optimal LDL-C and high high-density lipoprotein cholesterol, traditionally considered a protective factor against heart disease, does not guarantee someone will not experience ASCVD down the road, according to the guideline authors. Therefore, measuring other biomarkers can offer a more complete picture of cardiovascular risk and help inform decisions about whether lipid-lowering therapy is needed sooner rather than later.

In addition to the standard cholesterol test panel, the guidelines recommend assessing coronary artery calcium, lipoprotein (a), and apolipoprotein B to more precisely pinpoint ASCVD risk.

Considering Treatments

While statins are a tried and tested treatment option, many new pharmacologic therapies are available for people who experience side effects with statins, Khan said. “Other therapies like PCSK9 inhibitors, ezetimibe, and bempedoic acid are suitable alternatives,” she said. “All of these medications should be used in tandem with lifestyle modifications and behavioral interventions to have the greatest impact on reducing the risk for ASCVD.”

In some people, the guideline authors wrote, high cholesterol can begin to affect the risk for heart disease as early as childhood and adolescence due to heredity or lifestyle habits. Therefore, Orringer said, cholesterol screening is recommended for all children aged between 9 and 11 years who have not been previously screened.

“For children with first- or second-degree relatives with premature ASCVD, severe hypercholesterolemia, or familial hypercholesterolemia, it is reasonable to begin screening them with a lipid profile beginning at age 2,” Orringer said.

Evidence continues to show that people who maintain low levels of LDL-C and triglycerides at a younger age are less likely to develop ASCVD later in life, the authors wrote, adding that the use of PREVENT-ASCVD, along with coronary artery calcium scoring and lipoprotein (a) measurement, allows clinicians to determine which individuals are at increased risk and who can benefit from earlier treatment.