APSC Consensus Recommendations on Dyslipidemia

6 CONSENSUS RECOMMENDATIONS - DYSLIPIDEMIA

• Patients with CCS should be assessed according to the Coronary–Vascular–Disease system (APSC CCS consensus recommendations) and categorized as having high-risk CCS (one risk factor) or very-high-risk CCS (>1 risk factor) (level of evidence, low; consensus, 96.3% agree)
• High-intensity statins are recommended for all patients with clinically manifest CCS, regardless of risk (level of evidence, moderate; consensus, 88.9% agree)
• LDL-C treatment targets for high-risk CCS: Reduction from baseline LDL-C of ≥50% and achieving an on-treatment level of at least <1.8 mmol/l (level of evidence, low; consensus, 96.3% agree)
• LDL-C treatment targets for very high-risk CCS: Reduction from baseline LDL-C of ≥50% and achieving an on-treatment level of at least <1.4 mmol/l (level of evidence, low; consensus, 96.3% agree)
• For high-risk CCS on maximally tolerated statins: Ezetimibe and/or a PCSK9i may be added for those who do not achieve target (level of evidence, moderate; consensus, 100% agree)
• For very-high-risk CCS:
  • Upfront initiation of combination therapy with high-intensity statins and ezetimibe may be considered
  • A PCSK9i may be added for those who do not achieve target within 4 weeks of initial therapy (level of evidence, moderate; consensus, 96.3% agree)

5 CONSENSUS RECOMMENDATIONS - FAMILIAL HYPERCHOLESTEROLEMIA

• Consideration of FH should be in people with:
  (1) Severely elevated LDL-C (in adults, >4.9 mmol/l; in children [aged ≤19 years], >3.9 mmol/l) (2) LDL-C of >2.6 mmol/l while adherent to a high-intensity statin (3) Premature ASCVD (age: men, <55 years; women, <60 years) (4) Elevated LDL-C (in adults >4.1 mmol/l) and a first-degree relative with premature CVD (5) A first-degree relative with FH, tendon xanthoma or arcus cornealis (level of evidence, low; consensus, 100% agree)
• Clinical criteria can be used to identify and diagnose suspected FH
• Choice of criteria may vary across and within countries) (level of evidence, low; consensus, 96.3% agree)
• Confirmation of FH via genetic testing is not necessary for treatment initiation but may be, for diagnostic confirmation and cascade screening to identify family members with FH (level of evidence, low; consensus, 100% agree)
• Once an index case is diagnosed, family cascade screening (lipid profile) is recommended (level of evidence, low; consensus, 96.3% agree)
• Patients with FH and ASCVD or another major CV risk factor are considered as very high risk
  • All other patients with FH are considered as high risk
  • These patients should be treated with LLTs in accordance with their risk profile (level of evidence, low; consensus, 96.3% agree)

3 CONSENSUS RECOMMENDATIONS – LIPOPROTEIN(a)

• Resources permitting Lp(a) measurement should be performed at least once in each adult person’s lifetime, especially those with family history of premature ASCVD
• Those with very high inherited Lp(a) levels >430 nmol/l (>180 mg/dl) may have a lifetime ASCVD risk equivalent to the risk associated with heterozygous FH (level of evidence, low; consensus, 92.6% agree)
• Consideration of Lp(a) measurement in selected patients with family history of premature CVD (level of evidence, low; consensus, 92.6% agree)
• As Lp(a) is a risk enhancer, measurement may be considered for between high- and very-high risk groups (level of evidence, low; consensus, 92.6% agree)