IJCS | Volume 32, Nº6, November / December 2019

DOI: https://doi.org/10.36660/ijcs.20190088 During the American Heart Association (AHA)’s scientific sessions held in November 2018, the new ultisociety Guideline on the Management of Blood Cholesterol 1 was presented to the cardiology community emphasizing some previous key recommendations and new concepts in atherosclerotic cardiovascular disease (ASCVD) prevention. The main updates of these guidelines are: 1) a new 10-y risk ASCVD categorization for adults 40 to 75 years of age and a lifetime risk estimation in young patients; 2) upgrading of non-statin therapies for LDL- cholesterol lowering treatment; 3) use of LDL-c thresholds (and not only of percental reduction) to consider intensification of therapy; 4) time of blood collection to measure lipid levels; 5) inclusion of the coronary artery calcium (CAC) score in the decision-making process in the management of intermediate-risk patients. A healthy lifestyle including an anti-atherogenic diet, physical activity, weight control and not smoking remains the cornerstone for cardiovascular prevention. Regardless of pharmacological treatment used, these habits are important at all ages, and are some of the key recommendations for ASCVD prevention. About the treatment with lipid-lowering drugs, statins remain as the first-choice agents. However, ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have gained attention as add-on drugs in a more aggressive approach for low-density lipoprotein cholesterol (LDL-c) reduction. Ezetimibe, a cholesterol absorption inhibitor, is the most commonly used drug in combination with statins, contributing for an additional 15-30% reduction in LDL-c levels. Considerable changes have been made in lipid- lowering therapy with the use of monoclonal antibodies that inhibit PCSK9, such as evolocumab and alirocumab. Based on studies showing an 1.5%absolute risk reduction in composite ASCVD outcomes in a follow-up of 2.2- 2.8 years, these new drugs are now recommended and should be included to therapy if lipid targets are not met after maximally tolerated doses of statin and ezetimibe. Recommendations are detailed below: - Established ASCVD: high-intensity statin should be indicated aiming at a ≥ 50% LDL-c reduction (and LDL-c < 70 mg/dl in those at very high ASCVD risk – Table 1). If this target is not achieved, ezetimibe should be added followed by PSCK9 inhibitors. The rationale is based on the findings that support the safety of extremely low LDL levels, and that, for LDL-c levels, “lower is better”. 2 - Primary prevention (Figure 1) - 10-year ASCVD risk calculation: the 10-y risk of ASCVD (calculated by the pooled cohort equation - PCE) is now categorized as: a. low (< 5%) – lifestyle changes are indicated; b. borderline (5% –< 7.5%) – the initiation of moderate- intensity statin therapy is recommended in selected cases; c. intermediate (7.5% –< 20%) – this is one of the main updates of the guideline. In the presence of risk- enhancing factors, it is suggested to start a moderate- intensity statin in this new group (Table 2). In addition, if the need for statin therapy by the patient remains uncertain (a common situation), the CAC score may 635 REVIEW ARTICLE International Journal of Cardiovascular Sciences. 2019;32(6):635-638 Mailing Address: Marcio Bittencourt Universidade de São Paulo – Hospital Universitário – Av. Lineu Prestes, 2565. Postal Code: 05508-000, Butantã, São Paulo, SP – Brazil. E-mail: msbittencourt@mail.harvard.edu New 2018 ACC/AHA Guidelines on Cholesterol Management: Key Changes and Implications Marcio Bittencour t a nd Giuliano Generos o Universidade de São Paulo, São Paulo, SP - Brazil Manuscript received on April 29, 2019; reviewed on July 31,2019; accepted on August 27,2019. Cardiovascular Diseases/ prevention and control; Lifestyle Physical, Activity; Weight Loss; Diet, Atherogenic; Cholesterol, Dietary. Keywords