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    ASCVD (Atherosclerotic Cardiovascular Disease) Risk Algorithm including Known ASCVD from AHA/ACC

    Determines 10-year risk of heart disease or stroke and provides statin recommendations.
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    Patients at risk for atherosclerotic cardiovascular disease (ASCVD).

    • In 2013 the American College of Cardiology (ACC) and the American Heart Association (AHA) released new guidelines for the evaluation and treatment of cholesterol in order to reduce the risk of atherosclerotic cardiovascular disease (ASCVD).
    • This calculator provides a simplified way to follow the ASCVD treatment algorithm, which includes specific advice for patients with known ASCVD (defined as: history of ACS, MI, stable angina, coronary/other arterial revascularization, stroke, transient ischemic attack, or PAD from atherosclerosis) and patients with extreme LDL levels (≥190 mg/dL / 4.92 mmol/L).
    • The ASCVD Risk Calculator is only appropriate for patients without ASCVD and with LDL levels 70-189mg/dL (1.81-4.90 mmol/L).
    • The treatment algorithm proposed by the ACC/AHA suggests aggressive treatment for many patients, but specifically notes that patients with known ASCVD and patients with extreme LDL levels (≥190 mg/dL / 4.92 mmol/L) are at the highest risk; it also provides the “intensity” of statin treatment based on patients' predicted risk levels.

    Points to keep in mind:

    • While the score was developed and validated in a large population, several studies have suggested that the risk calculator substantially over-estimates 10-year risk. Some studies have suggested that its risk estimates are accurate.
    • Statins are highly emphasized in the guidelines and recommendations, but lifestyle modifications are likely just as – if not more – important to ASCVD risk.

    The ASCVD Risk Algorithm is a standardized guideline to predict risk and recommend management strategies for those at risk of ASCVD.

    Step 1: High-Risk Criteria: History of ASCVD

    Result:

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    Advice

    When Considering Starting Statins

    First, always engage in a clinician-patient discussion of the potential for ASCVD risk reduction, adverse effects, drug-drug interactions, and patient preferences. Consider:

    • Potential for ASCVD risk-reduction benefits.
    • Potential for adverse effects and drug-drug interactions.
    • Heart-healthy lifestyle.
    • Management of other risk factors.
    • Patient preferences.

    See Table 8 for safety recommendations about statin usage.

    Statin therapy is not routinely recommended for individuals with New York Heart Association class II to IV heart failure or who are receiving maintenance hemodialysis.

    When Considering or Using High-Intensity Statins

    The guidelines recommend the treating clinician consider:

    • Multiple or serious comorbidities, such as impaired renal or hepatic function.
    • A history of previous statin intolerance or muscle disorders.
    • Unexplained elevated levels of alanine transaminase greater than three times the upper limit of normal.
    • Patient characteristics or concomitant use of medications that affect statin metabolism.
    • Age older than 75 years.

    When Considering Other Groups for Aggressive Cholesterol-Lowering Medications Besides Those in the Risk Calculator

    The guidelines recommend the treating clinician consider patients with:

    • A primary LDL-C level of 160 mg per dL (4.14 mmol per L) or greater, or other evidence of genetic hyperlipidemias.
    • Family history of premature ASCVD before 55 years of age in a first-degree male relative or before 65 years of age in a first-degree female relative.
    • High-sensitivity C-reactive protein level of 2 mg per L (19.05 nmol per L) or greater.
    • Coronary artery calcium score of 300 Agatston units or greater, or being in the 75th percentile or greater for age, sex, and ethnicity.
    • Ankle-brachial index (ABI) less than 0.9.
    • Elevated lifetime risk of ASCVD.

    When Monitoring Statin Effects and Side Effects

    • Assess adherence, response to therapy, and adverse effects within 4 to 12 weeks following statin initiation or change in therapy.
    • Measure fasting lipid levels.
    • Do not routinely monitor alanine transaminase or creatine kinase levels unless symptomatic.
    • Screen and treat type 2 diabetes according to current practice guidelines; heart-healthy lifestyle habits should be encouraged to prevent progression to diabetes.

    Formula

    Scoring information is available in Appendix 7 in the Goff, et al. 2014 study.

    Facts & Figures

    • These estimates may underestimate the 10-year risk for some race/ethnic groups, including American Indians, some Asian Americans (e.g., of south Asian ancestry), and some Hispanics (e.g., Puerto Ricans).
    • It may overestimate the risk for some Asian Americans (i.e., of east Asian ancestry) and some Hispanics (i.e., Mexican Americans).
    • Because the primary use of these risk estimates is to facilitate the very important discussion regarding risk reduction through lifestyle change, the imprecision introduced is small enough to justify proceeding with lifestyle change counseling informed by these results.

    US Preventive Services Task Force (USPSTF) Guidelines

    In 2016, the US Preventive Services Task Force (USPSTF) made similar but slightly different recommendations for adults without a history of cardiovascular disease (CVD) to use a low- to moderate-dose statin for the prevention of CVD events and mortality when all of the following criteria are met:

    1. Age 40 to 75 years
    2. 1 or more CVD risk factors (ie, dyslipidemia, diabetes, hypertension, or smoking)
    3. Calculated 10-year risk of a cardiovascular event of 10% or greater (B recommendation)

    The USPSTF gave a B recommendation—indicating high certainty that the benefit is moderate or moderate certainty that the benefit is moderate to substantial—for starting low- to moderate-dose statins in adults ages 40 to 75 years without a history of cardiovascular disease (CVD) who have one or more CVD risk factors and a 10-year CVD risk of 10% or greater.

    The USPSTF dropped its level of endorsement to C for adults with a lower 1-year risk (7.5%-10%) and made no recommendations for adults 76 years of age and older, explaining that there was insufficient evidence for this age group.

    *Thanks to Vijay Shetty, MBBS, for this summary of the 2016 USPSTF guidelines.

    Intensity of Statin Therapy

    Type of Statin Taken Daily, Average LDL Lowering Effect Types of Medication
    High-Intensity Statin Therapy Approximately ≥50% Atorvastatin 40–80 mg
    Rosuvastatin 20-40 mg
    Moderate-Intensity Statin Therapy Approximately 30% to <50% Atorvastatin 10-20 mg
    Rosuvastatin 5-10 mg
    Simvastatin 20–40 mg
    Pravastatin 40-80 mg
    Lovastatin 40 mg
    Fluvastatin XL 80 mg
    Fluvastatin 40 mg
    BID Pitavastatin 2–4 mg
    Low-Intensity Statin Therapy Approximately <30% Simvastatin 10 mg
    Pravastatin 10–20 mg
    Lovastatin 20 mg
    Fluvastatin 20–40 mg
    Pitavastatin 1 mg

    Literature

    Dr. David Goff

    About the Creator

    David C. Goff, Jr., MD, PhD, is a professor of epidemiology at the University of Colorado and is the dean of the Colorado School of Public Health. He is a former recipient of the Public Policy Award from the National Forum for Heart Disease and Stroke Prevention, and he is currently the Interim Chair of the ASPPH accreditation and credentialing committee. His research interests include the prevention and understanding of heart disease and stroke.

    To view Dr. David Goff's publications, visit PubMed