Lp(a): A Toolkit for Health Care Professionals

18 For all people, emphasize a heart-healthy lifestyle, which reduces ASCVD risk at all ages. In younger people, a healthy lifestyle can lower risk of developing factors and is the foundation of ASCVD risk reduction. In young adults 20 to 39 years of age, assessing lifetime risk facilitates the clinician–patient risk discussion (see No. 6) and emphasizes intensive lifestyle efforts. In all age groups, lifestyle therapy is the primary intervention for metabolic syndrome. In patients with clinical ASCVD, reduce low-density lipoprotein cholesterol (LDL-C) with high-intensity statin therapy or maximally tolerated statin therapy. The more LDL-C is reduced on statin therapy, the greater subsequent risk reduction. Use a maximally tolerated statin to lower LDL-C levels by ≥50%. In very-high-risk ASCVD, use an LDL-C threshold of 70 mg/ dL (1.8 mmol/L) to consider addition of non-statins to statin therapy. Very high risk includes a history of multiple major ASCVD events or one major ASCVD event and multiple high-risk conditions. In very-high-risk ASCVD patients, it’s reasonable to add ezetimibe to maximally tolerated statin therapy when the LDL-C level remains ≥70 mg/dL (≥1.8 mmol/L). In patients at very high risk whose LDL-C level remains ≥70 mg/dL (≥1.8 mmol/L) on maximally tolerated statin and ezetimibe therapy, adding a PCSK9 inhibitor is reasonable, although the long-term safety (>3 years) is uncertain and cost effectiveness is low at mid-2018 list prices. It is reasonable to consider lipoprotein apheresis when other measures are insufficient to reach LDL threshold. 2018 AHA/ACC Cholesterol Guidelines Top 10 Takeaways Currently, there is no treatment for elevated Lp(a), but clinicians can make sure their patients’ LDL levels and triglycerides are well controlled according to the current guidelines. 1 2 3