Research and Literature

Professional Refresher: AHA/ACC Guidelines on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: Monitoring Statin Therapy

January 11, 2017   /

What are these guidelines?
The American Heart Association (AHA) and the American College of Cardiology (ACC) began work in 2008 to compile and transform evidenced-based research and outcomes into doable guidelines to better the heart health of the American people. 

How were the guidelines created?
Work groups, consisting of health professionals and researchers in the field, were formed. Each group looked at a different component of heart health and compiled the best and most relevant research studies and results. These work groups then established guidelines based on the available evidence. 

How can they help me and my family?
These guidelines are intended to guide physicians and health professionals to better reduce the risk for cardiovascular events, like heart attacks and high blood pressure, in their patients.  

What are the specific guidelines?
The Guidelines on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults were divided into 3 components: 1) statin treatment recommendations, 2) safety recommendations, and 3) recommendations for monitoring, optimizing, and addressing insufficient response to statin therapy. Due to the length of these specific guidelines, each component has been separated into its own document. The remaining 4 components, as well as other sets of guidelines from the report, can be found at www.nutrtion411.com in the Heart Health Information Center.
The guidelines below are copied directly from the report, which can be viewed at http://circ.ahajournals.org/content/129/25_suppl_2/S1.full
Component 3: Recommendations for Monitoring, Optimizing, and Addressing Insufficient Response to Statin Therapy

Monitoring Statin Therapy
Adherence to medication and lifestyle, therapeutic response to statin therapy, and safety should be regularly assessed. This should include a fasting lipid panel performed within 4 - 12 weeks after initiation or dose adjustment, and every 3 - 12 months thereafter. Other safety measurements should be measured as clinically indicated.

Optimizing Statin Therapy
The maximum tolerated intensity of statin should be used in individuals for whom a high- or moderate-intensity statin is recommended but not tolerated.

Insufficient Response to Statin Therapy

  1. In individuals who have a less-than-anticipated therapeutic response or are intolerant of the recommended intensity of statin therapy, the following should be performed:
    1. Reinforce medication adherence
    2. Reinforce adherence to intensive lifestyle changes
    3. Exclude secondary causes of hyperlipidemia
  2. It is reasonable to use the following as indicators of anticipated therapeutic response to the recommended intensity of statin therapy. Focus is on the intensity of the statin therapy. As an aid to monitoring: 
    1. High-intensity statin therapy general results in an average low density lipoprotein cholesterol (LDL-C) reduction of ≥ 50% from the untreated baseline.
    2. Moderate-intensity statin therapy generally results in an average LDL-C reduction of 30% to < 50% from the untreated baseline.
    3. LDL-C levels and percentage reduction are to be used only to assess response to therapy and adherence. They are not to be used as performance standards. 
  3. In individuals at higher atherosclerotic cardiovascular disease (ASCVD) risk receiving the maximum tolerated intensity of statin therapy who continue to have a less-than-anticipated therapeutic response, addition of nonstatin cholesterol-lowering drug(s) may be considered if the atherosclerotic cardiovascular disease (ASCVD) risk-reduction benefits outweigh the potential for adverse effects.
    1. Higher-risk individuals include:
      1. Individuals with clinical ASCVD < 75 years of age.
      2. Individuals with baseline LDL-C ≥ 190 mg/dL.
      3. Individuals 40 - 75 years with diabetes.
    2. Preference should be given to the nonstatin cholesterol-lowering drugs shown to reduce ASCVD events in randomized controlled trials (RCTs). 
  4. In individuals who are candidates for statin treatment but are completely statin intolerant, it is reasonable to use nonstatin cholesterol-lowering drugs that have been shown to reduce ASCVD events in RCTs if the ASCVD risk-reduction benefits outweigh the potential for adverse effects. 

How can I use these guidelines to help my patients?
Registered dietitian nutritionists (RDNs) can use these guidelines to help patients evaluate the risks and benefits for medications for cardiovascular disease (CVD) and if medication changes are needed. Referral to a physician may be necessary. 

References and recommended readings
Stone N, Jennifer R, Lichtenstein A, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Circulation. 2013;129:S1-S45. doi:10.1161/01.cir.9999437738.63853.7a.