ACC/AHA versus NLA Guidelines for Cholesterol Management

Las Vegas—In 2013, the American College of Cardiology (ACC) and the American Heart Association (AHA) released joint cholesterol management guidelines, which were considered controversial by some in the industry. A year later, the National Lipid Association (NLA) released their own set of cholesterol guidelines that differed from the ACC/AHA recommendations.

During a workshop at the Cardiometabolic Risk Summit, Peter H. Jones, MD, FACP, FNLA, associate professor, Houston Methodist DeBakey Heart and Vascular Center, Baylor College of Medicine, and Louis Kuritzky, MD, clinical assistant professor, family medicine residency program, University of Florida, discussed the ACC/AHA and NLA guidelines, including the recommendations for treatment and the differences between the 2.

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Although both guidelines are patient-centric and intended for adults ≥18 years of age, there are significant differences. The ACC/AHA guidelines list 4 factors that warrant consideration of pharmacotherapy: (1) atherosclerotic cardiovascular disease (ASCVD); (2) diabetes mellitus; (3) low-density lipoprotein (LDL) cholesterol ≥190 mg/dL; and (4) 10-year cardiovascular disease risk ≥7.5%.

According to a study, there are 3 factors that warrant high-intensity statin therapy: (1) ASCVD in patients <75 years of age; (2) diabetes in patients with >7.5% risk; and (3) patient with LDL cholesterol ≥190 mg/dL. The ACC/AHA guidelines define high-intensity statin therapy as a daily dosage that lowers LDL cholesterol approximately 50% and can be achieved with atorvastatin 40 mg to 80 mg per day or rosuvastatin 20 mg to 40 mg per day.  

Patients should receive moderate-intensity statin therapy if they are diagnosed with ASCVD and are >75 years of age, diagnosed with diabetes with a 10-year ASCVD risk <7.5%, or are between 40 to 75 years of age with a 10-year ASCVD risk ≥7.5%. Moderate-intensity statin therapy is defined as a daily dosage that lowers LDL cholesterol approximately 30% to 50%. There are multiple statins that can achieve this goal, including:

            • Atorvastatin – 10 mg to 20 mg per day

            • Fluvastatin – 80 mg per day

            • Lovastatin – 40 mg per day

            • Pitavastatin – 2 mg to 4 mg per day

• Pravastatin – 40 mg to 80 mg per day

• Rosuvastatin – 5 mg to 10 mg per day

• Simvastatin – 20 mg to 40 mg per day

One of the major controversies is that the ACC/AHA guidelines do not make recommendations for specific LDL cholesterol goals or non–high-density lipoprotein (HDL) cholesterol goals for primary and secondary ASCVD prevention.

Drs. Jones and Kuritzky then reviewed the NLA guidelines, which include 4 leading principles: (1) patients with dyslipidemia require lifestyle intervention in an effort to reduce the risk of ASCVD, regardless of pharmacotherapy; (2) intensity of risk reduction therapy should be adjusted to a patient’s absolute risk for an ASCVD event; (3) statin therapy is the primary modality for reducing ASCVD risk unless contradicted; and (4) other ASCVD risk factors should be managed appropriately.

The NLA guidelines set a primary prevention goal of non-HDL cholesterol <130 mg/dL and LDL cholesterol <100 mg/dL. The secondary prevention goal is non-HDL cholesterol <100 mg/dL and LDL cholesterol <70 mg/dL if the patient has ASCVD or diabetes and in addition to ≥2 major ASCVD risk factors.

First-line therapy for elevated atherogenic cholesterol levels is moderate- or high-intensity statin therapy. Contrary to the ACC/AHA guidelines, the NLA guidelines state nonstatin therapy should be considered for patients with contradictions. Statin therapy supplemented by a second or third agent may be considered for patients who have not reached goals for atherogenic cholesterol levels.—Melissa D. Cooper