J Korean Med Assoc.  2014 Oct;57(10):857-865. 10.5124/jkma.2014.57.10.857.

The ideal management of blood cholesterol: a review of the updated 2013 ACC/AHA cholesterol guideline for reducing cardiovascular risk

• Choi HI
• Han KH

• KMID: 1958385
• DOI: http://doi.org/10.5124/jkma.2014.57.10.857

Abstract

Atherosclerotic cardiovascular disease (ASCVD) is the most important public health problem worldwide in terms of the size of expenditures in most healthcare budgets. In November 2013, the American College of Cardiology and American Heart Association (ACC/AHA) released a clinical practice guideline on the treatment of blood cholesterol to reduce ASCVD risk in adults. Based on the design and results of the randomized clinical trials and meta-analyses published through July 2013, four groups of individuals were identified for whom an extensive body of randomized clinical tria evidence demonstrated a clear reduction in ASCVD events from statin therapy with a good margin of safety. Together with ASCVD, in severe hypercholesterolemic (low-density lipoprotein cholesterol > or =190 mg/dL) or diabetic subjects, the guideline recommends the use of statins if the newly-developed Pooled Cohort Equations estimate a 10-year ASCVD risk of equal to or higher than 7.5%. The guideline recommendations represent a new paradigm for treating cholesterol focused on using the appropriate intensity of statin therapy for those most likely to benefit, while the guideline has eliminated low-density lipoprotein cholesterol and non-high-density lipoprotein cholesterol targets. Non-statin therapies were discouraged due to the lack of evidence for their production of acceptable ASCVD risk reduction benefits. This radical shift away from the set of previous guidelines has created controversy and confusion. This article reviews the 2013 ACC/AHA guideline for the treatment of blood cholesterol to reduce ASCVD risk in adults and the optimal strategies for using this guideline in clinical practice.

Keyword

Guideline; Cholesterol; Cardiovascular risk; Statin

MeSH Terms

Adult
American Heart Association
Budgets
Cardiology
Cardiovascular Diseases
Cholesterol*
Cohort Studies
Delivery of Health Care
Health Expenditures
Humans
Hydroxymethylglutaryl-CoA Reductase Inhibitors
Lipoproteins
Public Health
Risk Reduction Behavior
Cholesterol
Lipoproteins

Figure

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  Figure 1 Statin therapy in patients with clinical atherosclerotic cardiovascular disease. If low-density lipoprotein cholesterol (LDL-C) <40 mg/dL, lower statin dose or switch to lower intensity statins with evidence. If LDL-C >100 mg/dL, check compliance and increase statin dose or switch to higher intensity statins with evidence or consider adding nonstatins. ICA, intracranial artery.

• 

  Figure 2 Statin therapy in patients without clinical atherosclerotic cardiovascular disease (ASCVD). Potentiate statin therapy if low-density lipoprotein cholesterol (LDL-C) >100 mg/dL after statin therapy 1) subclinical atherosclerosis, 2) overt family history of dyslipidemia or ASCVD, and 3) high CRP levels ≥2 mg/dL. a) Consider risk-benefit and needs patients' agreement.

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