Cardiovascular prevention: Frontiers in lipid guidelines

Eun Ji Kim; Anthony S Wierzbicki

doi:10.7861/clinmed.cme.20.1.2

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Table 1.

Comparison of principal components of guidelines for management of cardiovascular disease risk in the USA, Europe and UK

	ACC/AHA			ESC/EAS			NICE
Initiation threshold for intervention	LDL-C >4.9 mmol/L ASCVD risk >7.5% DM and age 40–75 years				Total CVD risk, score %	LDL-C, mmol/L
				Primary prevention	Low risk, >1	≥4.9	Primary prevention	>10% CVD risk or FH
					Borderline risk, >1 to <5	≥4.9
					Moderate risk, >5 to <10	≥2.6
					High risk, >10	≥1.8
				Secondary prevention	Very high-risk	≥1.4	Secondary prevention	All CVD including peripheral arterial disease
Risk measures calculator system, age range and components	Pooled cohort equations (PCE)			European SCORE calculator (fatal CVD only)			QRISK2 (QRISK3) in England and Wales, ASSIGN in Scotland
	40–75 years Age Gender Smoking Systolic blood pressure Total cholesterol HDL-cholesterol			40–70 years Low-risk vs high-risk regions of Europe Age Gender Smoking Systolic blood pressure Total cholesterol			35–75 (25–85) years Age Gender Smoking Systolic blood pressure Total cholesterol HDL-cholesterol Deprivation Ethnicity Family history of CVD (<60 years) Treated blood pressure Atrial fibrillation CKD3 T2DM Autoimmune disease (RA)
Additional CVD risk factors	Family history CVD (male <55 years; female <65 years) Metabolic syndrome Coronary Artery Calcium Score >100 Lp(a) >50 mg/dL (125 nmol/L) ApoB >130 mg/dL CRP >2 mg/L Chronic kidney disease Chronic inflammation Premature menopause High-risk race/ethnicity Persistent LDL-C >4.1 mmol/L or triglycerides >2.0 mmol/L Ankle-brachial index <0.9			Family history CVD <55 years Social deprivation HIV Major psychiatric disease Chronic autoimmune disease Obesity (central or morbid) Obstructive sleep apnoea Atrial fibrillation Left ventricular hypertrophy Non-alcoholic fatty liver disease Physical inactivity/psychosocial stress Carotid or femoral plaques Coronary artery calcium score >100 Ankle-brachial index <0.9 or >1.40 Carotid-femoral pulse wave velocity >10 m/s Lp(a) elevation >180 mg/dL (430 nmol/L) ApoB (see targets) Triglycerides >2.3 mmol/L CRP >2 mg/dL Albuminuria			Many added in QRISK3 (2017) T1DM Systemic lupus erythematosus Major psychiatric disease: use of atypical antipsychotics Use of steroid therapy
Targets for primary prevention by risk category	LDL-C mmol/L	ASCVD risk estimation, %	Goal of LDL-C reduction	SCORE, %	Target LDL-C, mmol/L	Non-HDL-C, mmol/L, and ApoB, mg/dL	No target, start moderate intensity statin eg atorvastatin 20 mg or equivalent increment for additional risk, adherence check if non-HDL-C change <40%
	>4.9	Regardless of ASCVD risk	Highest intensity statin	>10 (or very high-risk)	<1.4	<2.2 and <65
	1.8–4.9	High risk, >20	Statin to reduce LDL-C, >50%	>5 to <10	<1.8	<2.6 and <85
		Intermediate, 7.5–20	Statin to reduce LDL-C, 30–40%	1–5	<2.6	<3.4 and <100
		Borderline, 5–7.5	Discuss moderate dose statin	<1	<3.0
Targets for secondary prevention	LDL-C <1.8 mmol/L Very-high risk group LDL-C <1.4 mmol/L			LDL <1.4 mmol/L 2nd ASCVD event LDL-C <1.0 mmol/L		Non-HDL-C <2.2 mmol/L and ApoB <65 mg/dL	No target, high dose high intensity statin eg atorvastatin 80 mg and ezetimibe (some cases), adherence check if non-HDL-C change <40%
Definition of very high-risk patients	LDL-C >4.9 mmol/L ASCVD risk >20% Previous CVD			ASCVD, either clinical or diagnosed on imaging DM with target organ damage or >3 major risk factors or T1DM (>20 years duration) Severe CKD (CKD4) SCORE >10% FH with ASCVD or another risk factor			n/a
Criteria for use of PCSK9-inhibitor	FH or recurrent ACS (very high risk) LDL-C >2.5 mmol/L			FH or recurrent ACS (very high risk) Failure to reach LDL-C goal (based on risk) on maximal statin and ezetimibe			Primary prevention: FH with LDL-C >5 mmol/L Secondary prevention: CVD with LDL-C >4 mmol/L with monovascular disease, CVD with LDL-C >3.5 mmol/L with multivascular/recurrent disease

ACC = American College of Cardiology; ACS = acute coronary syndrome; AHA = American Heart Association; ApoB = apolipoprotein B; ASCVD = atherosclerotic cardiovascular disease; CVD = cardiovascular disease; CKD = chronic kidney disease; CRP = C-reactive protein; DM = diabetes mellitus; EAS = European Atherosclerosis Society; ESC = European Society of Cardiology; FH = familial hypercholesterolaemia; LDL-C = low-density lipoprotein cholesterol; Lp(a) = Lipoprotein (a); non-HDL-C = non-high-density lipoprotein cholesterol; PCSK9-inhibitor = proprotein convertase subtilisin kexin 9 inhibitor; RA = rheumatoid arthritis; SCORE = Systematic Coronary Risk Estimation chart for European populations; T1DM = type 1 diabetes mellitus; T2DM = type 2 diabetes mellitus.