New AACE Lipid Guidelines Establish 'Extreme' CVD Risk Category

AUSTIN, Texas — In a departure from recommendations by cardiology societies, two endocrine groups have issued new lipid-management guidelines that bring back LDL-cholesterol "targets" and are the first ever to include a new "extreme-risk" category of patients, for whom an LDL-cholesterol level of less than 55 mg/dL is now advised.

These latest guidelines from the American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE) are published in the April issue of Endocrine Practice and were discussed on May 4 in a workshop here at the AACE 2017 Annual Scientific & Clinical Congress.

"All the emerging data are saying the same thing: The lower the LDL cholesterol the better, regardless of where your LDL is to begin with," one of the guideline authors, Paul S Jellinger, MD, professor of clinical medicine, University of Miami Miller School of Medicine, Florida, told Medscape Medical News in an interview.

That evidence, he said, led the AACE and ACE to differ from the controversial American Heart Association /American College of Cardiology guidelines of 2013 that removed LDL targets and instead recommended varying intensities of statin therapy to four groups of primary- and secondary-prevention patients.

In contrast, AACE/ACE now recommend LDL goals of < 55 mg/dL, < 70 mg/dL, < 100 mg/dL, and < 130 mg/dL for individuals at extreme, very high, high/moderate, and low risk for cardiovascular events, respectively.  

"Targets are very, very useful. They're strong incentives for both patients and physicians. We have HbA1c goals, we have blood-pressure goals. Why shouldn't we have LDL goals? There is strong evidence that the lower, the better," Dr Jellinger emphasized.

Indeed, he noted that AACE/ACE has, in fact, "never left" LDL targets, as they were a key feature of their prior guidance.

But ACC/AHA guideline coauthor Jennifer G Robinson, MD, professor in the departments of epidemiology and medicine and director, Prevention Intervention Center, the University of Iowa, Iowa City, defended the ACC/AHA approach.

"It is unfortunate that [AACE/ACE] continues to perpetuate LDL-cholesterol and other lipid goals. Low LDL levels may be better — but it matters how you get there and in whom. Using LDL thresholds and considering potential for net benefit are better approaches for personalizing cholesterol-lowering therapy," she told Medscape Medical News.

Targets for Five CVD Risk Categories

The AACE/ACE guidelines divide patients into five atherosclerotic cardiovascular disease (ASCVD) risk categories:

Extreme-risk goals: LDL < 55 mg/dL, non-HDL < 80 mg/dL, apolipoprotein B (apoB) < 70 mg/dL

  • Progressive atherosclerotic cardiovascular disease (ASCVD), including unstable angina, in patients after achieving an LDL-C <70 mg/dL.

  •  Established clinical cardiovascular disease in patients with diabetes, chronic kidney disease (CKD) stages 3/4, or heterozygous familial hypercholesterolemia (HeFH).

  • History of premature ASCVD (< 55 years of age in men, < 65 in women).

Very high-risk goals: LDL < 70 mg/dL, non-HDL < 80 mg/dL, apoB < 80 mg/dL

  • Established or recent hospitalization for acute coronary syndrome, coronary, carotid, or peripheral vascular disease, 10-year risk > 20%.

  • Diabetes or CKD stages 3/4 with one or more risk factors.

  • HeFH.

High-risk goals: LDL < 100 mg/dL, non-HDL < 130 mg/dL, apoB < 90 mg/dL

  • Two or more risk factors and 10-year risk 10% to 20%.

  • Diabetes or CKD stages 3/4 with no other risk factors.