Updated ASCVD Recommendations Upgrade PCSK9 Inhibitors

The American College of Cardiology (ACC) has updated its expert consensus decision pathway for the use of non-statin drugs for the lowering of LDL cholesterol in patients with atherosclerotic cardiovascular disease (ASCVD). 

The update to the 2016 pathway comes in response to evidence of significant benefit in cardiovascular event reduction with the addition of evolucumab to statin therapy, with or without ezetimibe, as well as other new evidence.
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Updates to the 2016 pathway include: 

Adults with clinical ASCVD taking statins for secondary prevention and who have LDL levels of 70-189 mg/dL still have a threshold for net risk-reduction benefit of an LDL lowering of at least 50%. However, clinicians may now consider an LDL or less than 70 mg/dL or a non-HDL level of less than 100 mg/dL for all patients, regardless of comorbidity.

Ezetimibe or PCSK9 inhibitors can be considered for patients in this LDL range with comorbidities. PCSK9 inhibitors may be preferred as initial non-statin agents in individuals requiring more than 25% additional lowering of LDL.

Recommendations regarding bile acid sequestrantuse were down-graded. These agents should be used only as optional secondary agents in patients intolerant to ezetimibe. 

Clarification has been provided on diagnostic categories of heterozygous and homozygous familial hypercholesterolemia.

“This [expert consensus decision pathway] addresses current gaps in care for LDL-C lowering to reduce ASCVD risk and provides recommendations that build on the evidence base established by the 2013 ACC/AHA cholesterol guideline.”

“Recommendations attempt to provide practical guidance for clinicians and patients regarding the use of non-statin therapies to further reduce ASCVD risk in situations not covered by the guideline until such time as the scientific evidence base expands and cardiovascular outcomes trials are completed with new agents for ASCVD risk reduction.”

—Michael Potts

Reference:

Lloyd-Jones DM, Morris PB, Ballantyne CM, et al. 2017 Focused update of the 2016 ACC expert consensus decision pathway on the role of non-statin therapies for ldl-cholesterol lowering in the management of atherosclerotic cardiovascular disease risk [published online September 5, 2017]. JACC. doi: 10.1016/j.jacc.2017.07.745.