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Arnett et al 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease

Circulation. 2019;140:e596–e646. DOI: 10.1161/CIR.0000000000000678 September 10, 2019 e615 CLINICAL STATEMENTS AND GUIDELINES

elevated lifetime ASCVD risk and benefit from statin therapy.S4.3-33,S4.3-36 Increased ASCVD risk is seen with metabolic syndrome;S4.3-31 inflammatory diseases, including psoriasisS4.3-39 and rheumatoid arthritis; and HIV when treated with protease inhibitors.S4.3-40 The presence of risk-enhancing factors may affect the threshold for statin initiation or intensification. Lipoprotein (a) levels, especially in those with a family history of premature ASCVD, can increase risk.S4.3-27 However, no available RCT evidence supports lipoprotein (a) levels as a target of therapy. Moderate primary elevations of triglycerides, non–HDL-C (total cholesterol – HDL-C), and, if measured, apolipoprotein B can improve selection of those at increased ASCVD risk.S4.3-33

7 In adults at intermediate risk, coronary artery

calcium measurement can be effective for meaningfully reclassifying risk in a large proportion of individuals.S4.3-41–S4.3-55 In such intermediate-risk adults, those with coronary artery calcium ≥100 AU or coronary artery calcium ≥75th percentile have ASCVD event rates for which initiation of statin therapy is reasonable.S4.3-41 Those with coronary artery calcium scores of zero appear to have 10-year event rates in a lower range for which statin therapy may be of limited value. For those with coronary artery calcium scores of 1 to 99 AU, 10-year ASCVD event rates are 3.8%, 6.5%, and 8.3% for adults 45 to 54, 55 to 64, and 65 to 74 years of age, respectively,S4.3-34 indicating that risk reclassification is modest for individuals with coronary artery calcium scores of 1 to 99. Therefore, for patients with coronary artery calcium scores of 1 to 99, it is reasonable to repeat the risk discussion. If these patients remain untreated, repeat coronary artery calcium measurement in 5 years may have some value, but data are limited.S4.3-56,S4.3-57 Selected examples of candidates who might benefit from knowing that their coronary artery calcium scores are zero are listed in Table 6. Clinicians should not downclassify risk in patients who have coronary artery calcium scores of zero but who are persistent cigarette smokers, have diabetes, have a family history of ASCVD, or, possibly, have chronic inflammatory conditions. In the presence of these conditions, a coronary artery calcium of zero does not rule out risk from noncalcified plaque or increased risk of thrombosis.S4.3-58

8 Benefit from statin therapy is also seen in lower-

risk individuals.S4.3-35 For those in the 5% to <7.5% risk range, available generic statins are cost-effective.S4.3-59 Nonetheless, the challenge among those in a lower ASCVD risk category is to include those who would benefit, yet avoid casting too wide a net, to minimize treating those who would derive little benefit from statins. This risk group benefits greatly from a clinician–patient risk discussion. Clinicians should assess priorities for health care, perceived ASCVD risk, and prior risk reduction experiences and should use best practices for communicating risk to arrive at a shared risk decision. The presence of risk-enhancing factors is probably the best indicator favoring initiation of statin therapy (Table 3 in Section 2.2.).S4.3-60 Although a coronary artery calcium score can be useful in select individuals, it will be positive less often in this lower-risk group than in those with higher levels of ASCVD risk and is not recommended routinely.S4.3-41

Table 6.  Selected Examples of Candidates for Coronary Artery Calcium Measurement Who Might Benefit From Knowing Their Coronary Artery Calcium Score Is Zero

Coronary Artery Calcium Measurement Candidates Who Might Benefit from Knowing Their Coronary Artery Calcium Score Is Zero Patients reluctant to initiate statin who wish to understand their risk and potential for benefit more precisely Patients concerned about need to reinstitute statin therapy after discontinuation for statin-associated symptoms Older patients (men 55–80 y of age; women 60–80 y of age) with low burden of risk factorsS4.3-53 who question whether they would benefit from statin therapy Middle-aged adults (40–55 y of age) with PCE-calculated 10-year risk of ASCVD 5% to <7.5% with factors that increase their ASCVD risk, although they are in a borderline risk group. Caveats: If patient is at intermediate risk and if a risk decision is uncertain and a coronary artery calcium score is obtained, it is reasonable to withhold statin therapy unless higher-risk conditions, such as cigarette smoking, family history of premature ASCVD, or diabetes mellitus, are present and to reassess coronary artery calcium score in 5 to 10 years. Moreover, if coronary artery calcium scoring is recommended, it should be performed in facilities that have current technology and expertise to deliver the lowest radiation possible. ASCVD indicates atherosclerotic cardiovascular disease; LDL-C, low-density lipoprotein cholesterol; and PCE, pooled cohort equations. Reproduced with permission from Grundy et al.S4.3-1 Copyright © 2018, American Heart Association, Inc., and American College of Cardiology Foundation.

Table 5.  Diabetes-Specific Risk Enhancers That Are Independent of Other Risk Factors in Diabetes Mellitus

Risk Enhancers in Diabetic Patients Long duration (≥10 years for T2DMS4.3-61 or ≥20 years for type 1 diabetes mellitusS4.3-16) Albuminuria ≥30 mcg albumin/mg creatinineS4.3-62 eGFR <60 mL/min/1.73 m2S4.3-62 RetinopathyS4.3-63 NeuropathyS4.3-64 ABI <0.9S4.3-65,S4.3-66 ABI indicates ankle-brachial index; eGFR, estimated glomerular filtration rate; and T2DM, type 2 diabetes mellitus. Reproduced with permission from Grundy et al.S4.3-1 Copyright © 2018, American Heart Association, Inc., and American College of Cardiology Foundation.

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