IJCS | Volume 32, Nº6, November / December 2019

636 Table 1 - Established ASCVD and High-Risk Factors Major ASCVD ACS within the past 12 months History of MI (other than recent ACS event listed above) History of ischemic stroke Symptomatic peripheral arterial disease High-Risk Conditions Age ≥ 65 y Heterozygous familial hypercholesterolemia History of prior coronary artery bypass surgery or percutaneous coronary intervention outside of the major ASCVD event(s) Diabetes mellitus Hypertension CKD (eGFR 15-59 mL/min/1.73 m 2 ) Current smoking Persistently elevated LDL-C (LDL-C ≥100 mg/dl) despite maximally tolerated statin therapy and ezetimibe History of congestive HF ABI: indicates ankle-brachial index; ACS: acute coronary syndrome; ASCVD: atherosclerotic cardiovascular disease; CKD: chronic kidney disease; eGFR: estimated glomerular filtration rate; HF: heart failure; LDL: low-density lipoprotein cholesterol; and MI, myocardial infarction. be a reasonable tool for assessing the risk of ASCVD in these patients. Since the CAC score is the tool that best adds predictive value of cardiovascular outcomes to risk calculators, 3 its use is recommended by the most recent guidelines when drug treatment is not well defined. Thus, in case of a CAC score of 1 to 99 Agatston units, introduction of pharmacological therapy should be individualized, particularly in those ≥ 55 years of age. 4 Also, in any patient with CAC ≥ 100 Agatston or ≥ 75 th percentile (regardless of the CAC score), statin therapy should be introduced. On the other hand, in individuals with a CAC of zero, statin therapy may be withheld or delayed, considering the very low incidence of cardiovascular events observed in this population. 5 d. high risk (≥20%) – as recommended in the previous statement, high-intensity statin is indicated aiming at reducing LDL-c levels by ≥50%. - Specific Situations - Severe hypercholesterolemia (LDL-c ≥190 mg/dl): high-intensity statins are indicated, with not need for risk calculation. Ezetimibe should be added if LDL-c reduction is ≤ 50% or remains ≥ 100 mg/dl. This group, composed mostly of people with familial hypercholesterolemia, received special attention due to the high rate of cardiovascular events, corresponding to 3-4-fold higher risk compared with other individuals with the same LDL-c levels. - Diabetes: patients aged 40-75 years old with diabetes should be treated with moderate-intensity statin and, in case of a 10-y ASCVD risk ≥ 20%, high-intensity statin should be added. These updated recommendations highlight a more personalized approach, with a follow-up of lipid profile for up to 20 years-old, with reassessment every 4-6 years. If pharmacological therapy is implemented, a closer follow-up is recommended to check LDL-c levels, safety and adherence. Regarding young adults (20 to 39 years of age), it is crucial to exclude secondary causes of hypercholesterolemia, as hypothyroidism (TSH), obstructive liver disease, renal disease and nephrosis, as well as dietary and medication-related dyslipidemia. Also, as mentioned before, intensive lifestyle change is strongly indicated due to its potential to reduce ASCVD risk. For young adults with persistent hypercholesterolemia (LDL-c levels above 160-189 mg/dL), it is recommended to consider risk- enhancing factors in the decision on whether to prescribe statins. For all patients with LDL-c ≥ 190 mg/dl, treatment should be conducted as previously described in “severe hypercholesterolemia” section. Lifestyle therapies are also pivotal in the management of children and adolescents with abnormal lipid values, aiming to treat obesity and other ASCVD risk factors. Also, this helps to identify individuals who would clearly benefit from statins,6 especially among those with persistent LDL-c ≥ 190mg/dl (or LDL-c ≥ 160mg/dl with familial hypercholesterolemia). Due to the very early atherogenic process in familial hypercholesterolemia, children and adolescents with a family history of early ASCVD or severe hypercholesterolemia should be evaluated for lipid profile as early as age of 2 years. Once hypercholesterolemia is detected, a comprehensive family screening is recommended to detect familial forms of hypercholesterolemia. Bittencourt & Generoso New ACC/AHA cholesterol guidelines Int J Cardiovasc Sci. 2019;32(6):635-638 Review Article