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June 18/25, 2019 Circulation. 2019;139:e1082–e1143. DOI: 10.1161/CIR.0000000000000625 e1112

CLINICAL STATEMENTS AND GUIDELINES

of specificity of the term Hispanic/Latino. Race/ethnicity and country of origin, together with socioeconomic status and acculturation level, should be discussed and may explain ASCVD risk factor burden more precisely than the generic term Hispanic/Latino.S4.5.1-6–S4.5.1-11 In addition, those who identify as Native American/Alaskan natives have high rates of risk factors for ASCVD compared to non-Hispanic whites. In many ways, the increase in metabolic risk factors and propensity for diabetes mellitus resembles the risk profiles of those who identify as Mexican-Americans.S4.5.1-12 Table 10 reviews these and other racial/ethnic issues that may be useful in clinical management. 4.5.2 Hypertriglyceridemia

Recommendations for Hypertriglyceridemia Referenced studies that support recommendations are summarized in Online Data Supplements 31 and 32.

COR LOE Recommendations

I B-NR 1.  In adults 20 years of age or older with moderate hypertriglyceridemia (fasting or nonfasting triglycerides 175 to 499 mg/dL [2.0 to 5.6 mmol/L]), clinicians should address and treat lifestyle factors (obesity and metabolic syndrome), secondary factors (diabetes mellitus, chronic liver or kidney disease and/or nephrotic syndrome, hypothyroidism), and medications that increase triglycerides.S4.5.2-1

CAC scoreS4.5.1-27–S4.5.1-30 In terms of CAC burden, South Asian men were similar to non- Hispanic white men, but higher CAC when than blacks, Latinos, and Chinese Americans. South Asian women had similar CAC scores to whites and other racial/ethnic women, although CAC burden higher in older age.S4.5.1-31 CAC predicts similarly in whites and in those who identify as Hispanic/Latino. In MESA, CAC score was highest in white and Hispanic men, with blacks having significantly lower prevalence and severity of CAC. Risk factor differences in MESA between ethnicities did not fully explain variability in CAC. However, CAC predicted ASCVD events over and above traditional risk factors in all ethnicities.S4.5.1-32 Treatment Lifestyle counseling (use

principles of Mediterranean and DASH diets) Use lifestyle counseling to recommend a hearthealthy diet consistent with racial/ethnic preferences to avoid weight gain and address BP and lipids. Use lifestyle counseling to recommend a hearthealthy diet consistent with racial/ ethnic preferences to avoid weight gain and address BP and lipids. Use lifestyle counseling to recommend a hearthealthy diet consistent with racial/ ethnic preferences to avoid weight gain and address BP and lipids. Asian and Hispanic/ Latino groups need to be disaggregated because of regional differences in lifestyle preferences. Challenge is to avoid increased sodium, sugar, and calories as groups acculturate. Intensity of statin therapy

and response to LDL- Clowering Japanese patients may be sensitive to statin dosing. In an open-label, randomized primaryprevention trial, Japanese participants had a reduction in CVD events with lowintensity doses of pravastatin as compared with placebo.S4.5.1-33 In a secondary-prevention trial, Japanese participants with CAD benefitted from a moderate-intensity dose of pitavastatin.S4.5.1-34 No sensitivity to statin dosage is seen, as compared with non-Hispanic white or black individuals. No sensitivity to statin dosage is seen, as compared with non-Hispanic white individuals. Using a lower statin intensity in Japanese patients may give results similar to those seen with higher intensities in non-Japanese patients. Safety Higher rosuvastatin plasma levels are seen in Japanese, Chinese, Malay, and Asian Indians as compared with whites.S4.5.1-35–S4.5.1-37 FDA recommends a lower starting dose (5 mg of rosuvastatin in Asians vs. 10 mg in whites). Caution is urged as dose is uptitrated There are no specific safety issues with statins related to Hispanic/Latino ethnicity.S4.5.1-38 Baseline serum CK values are higher in blacks than in whites.S4.5.1-39 The 95th percentile race/ ethnicity- specific and sexspecific serum CK normal levels are available for assessing changes in serum CK. Clinicians should take Asian race into account when prescribing dose of rosuvastatin (See package insert). In adults of East Asian descent, other statins should be used preferentially over simvastatin.S4.5.1-5 *The term Asian characterizes a diverse portion of the world’s population. Individuals from Bangladesh, India, Nepal, Pakistan, and Sri Lanka make up most of the South Asian group.S4.5.1-26 Individuals from Japan, Korea, and China make up most of the East Asian group. †The term Hispanics/Latinos in the United States characterizes a diverse population group. This includes white, black, and Native American races. Their ancestry goes from Europe to America, including among these, individuals from the Caribbean, Mexico, Central and South America. ASCVD indicates atherosclerotic cardiovascular disease; BP, blood pressure; CAC, coronary artery calcium; CAD, coronary artery disease; CK, creatine kinase; CVD, cardiovascular disease; DASH, Dietary Approaches to Stop Hypertension; DM, type 2 diabetes mellitus; FDA, US Food and Drug Administration; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; MESA, Multi-Ethnic Study of Atherosclerosis; MetS, metabolic syndrome; and PCE, pooled cohort equations.

Table 10.  Continued

Racial/Ethnic Groupings

Asian AmericansS4.5.1-4, S4.5.1-13* Hispanic/Latino AmericansS4.5.1-7–S4.5.1-11† Blacks/African AmericansS4.5.1-14 Comments

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