New AACE lipid guidelines introduce an “extreme” cardiovascular risk category

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New American Association of Clinical Endocrinologists and American College of Endocrinology (AACE/ACE) guidelines on management of dyslipidemia recommend more intense treatment and intervention – “lower the LDL cholesterol the better regardless of the baseline LDL”

The AACE/ACE guidelines have for the first time defined an “extreme” cardiovascular risk category. They also bring back “targets” for LDL-cholesterol in a major departure from the AHA/ACC guidelines issued in 2013, which had done away with LDL- and non-HDL–cholesterol targets and instead had recommended “appropriate intensity” of statin therapy for the four groups of primary- and secondary-prevention patients.
The new AACE/ACE guidelines have defined five atherosclerotic cardiovascular disease risk categories and set out lipid goals for each category.

Goals: LDL < 55 mg/dL, non-HDL < 80 mg/dL, apolipoprotein B (apoB) < 70 mg/dL
• Progressive atherosclerotic cardiovascular disease (ASCVD), including unstable angina, in patients after achieving an LDL-C <70 mg/dL.
• Established clinical cardiovascular disease in patients with diabetes, chronic kidney disease (CKD) stages 3/4, or heterozygous familial hypercholesterolemia (HeFH).
• History of premature ASCVD (< 55 years of age in men, < 65 in women).
Very high-risk
Goals: LDL < 70 mg/dL, non-HDL < 80 mg/dL, apoB < 80 mg/dL
• Established or recent hospitalization for acute coronary syndrome, coronary, carotid, or peripheral vascular disease, 10-year risk > 20%.
• Diabetes or CKD stages 3/4 with one or more risk factors.
• HeFH
Goals: LDL < 100 mg/dL, non-HDL < 130 mg/dL, apoB < 90 mg/dL
• Two or more risk factors and 10-year risk 10% to 20%.
• Diabetes or CKD stages 3/4 with no other risk factors.
Moderate risk
Same goals as high risk
Two or more risk factors and 10-year risk < 10%.
Goals: LDL < 130 mg/dL, non-HDL < 160 mg/dL, apoB not relevant)
0 risk factors

Additionally, these guidelines also support the measurement of coronary artery calcium (CAC) score and inflammatory markers to stratify risk.

These guidelines were the focus of discussion in a workshop at the ongoing 26th Annual Scientific and Clinical Congress of the American Association of Clinical Endocrinologists in Austin, Texas and also published in the April 2017 issue of the Endocrine Practice.

High blood cholesterol is a major risk factor for heart disease. Higher the blood cholesterol level, the greater the risk for developing heart disease or suffering a heart attack.

High blood cholesterol itself does not cause symptoms. Therefore, many people remain unaware of their high cholesterol levels.

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%. Regular exercise can increase HDL cholesterol levels.

(Source: Tucker. New AACE lipid guidelines establish ‘extreme’ CVD risk category – Medscape – May 05, 2017; AACE Press Release, May 4, 2017)

Dr KK Aggarwal

National President IMA & HCFI