Department of Family Medicine (Dr. Wójcik) and Center for Preventive Cardiology, Knight Cardiovascular Institute (Dr. Shapiro), Oregon Health & Science University, Portland cezarywojcik2000@ gmail.com
Dr. Wójcik reported no potential conflict of interest relevant to this article.
Dr. Shapiro serves as a consultant to Amarin Corporation, is on the advisory board of Esperion Therapeutics, Inc., and has contracted research with Akcea Therapeutics, Inc. and The FH Foundation. His work is supported by NIH K12HD043488.
Fasting vs nonfasting lipid profiles. In contrast to previous guidelines,2,8 which used fasting lipid profiles, nonfasting lipid profiles are now recommended for establishing a baseline LDL-C level and for ASCVD risk estimation for most patients—as long as the triglycerides (TG) level is < 400 mg/dL. When the calculated LDL-C level is < 70 mg/dL using the standard Friedewald formula, obtaining a direct LDL-C or a modified LDL-C estimate9 is deemed reasonable to improve accuracy. (The modified LDL-C can be estimated using The Johns Hopkins Hospital’s free “LDL Cholesterol Calculator” [www.hopkinsmedicine.org/apps/all-apps/ldl-cholesterol-calculator]).
A fasting lipid profile is still preferred for patients who have a family history of a lipid disorder. The definition of hypertriglyceridemia has been revised from a fasting TG level ≥ 150 mg/dL to a nonfasting or fasting TG level ≥ 175 mg/dL.1
Nonstatin add-on therapy. The new guideline supports the addition of nonstatin therapies to maximally tolerated statin therapy in patients who have established ASCVD or a primary LDL-C elevation ≥ 190 mg/dL when (1) the LDL-C level has not been reduced by the expected percentage (≥ 50% for high-intensity statin therapy) or (2) explicit LDL-C level thresholds have been met.1
Although measurement of the coronary artery calcium score by CT is generally not covered by insurance, its cost ($50-$450) nationwide makes it accessible.
The principal 2 groups of recommended nonstatins for which there is randomized, controlled trial evidence of cardiovascular benefit are (1) the cholesterol-absorbing agent ezetimibe10 and (2) the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors evolocumab11 and alirocumab.12
AAFP’s guarded positions on the 2013 and 2018 guidelines
The American Academy of Family Physicians (AAFP) welcomed the patient-centered and outcome-oriented aspects of the 2013 ACC/AHA guidelines, endorsing them with 3 qualifications.13
Many of the recommendations were based on expert opinion, not rigorous research results—in particular, not on the findings of randomized controlled trials (although key points are based on high-quality evidence).
There were conflicts of interest disclosed for 15 members of the guidelines panel, including a vice chair.
Validation of the PCE risk estimation tool was lacking.
