April 1, 2016, American College of Cardiology -- The American College of Cardiology today released expert consensus guidance regarding the use of non-statin therapies to lower cholesterol in high-risk patients.

The purpose of the document, 2016 ACC Expert Consensus Decision Pathway on the Role of Non-Statin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk, is to provide practical guidance for clinicians and patients in situations not covered by the evidence-based 2013 ACC/American Heart Association Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults.

Consistent with the 2013 Guideline, this new document recommends looking first at lifestyle issues, including diet, exercise and smoking, followed by statin therapy.

“Lifestyle modification remains a critical component of cardiovascular disease risk reduction, both prior to and in concert with the use of cholesterol-lowering drug therapies,” said Pamela B. Morris, MD, FACC, FNLA, director of the Seinsheimer Cardiovascular Health Program at the Medical University of South Carolina, chair of the ACC Prevention of Cardiovascular Disease council, secretary of the southeast chapter of the National Lipid Association, and vice-chair of the writing committee. “This includes adhering to a heart healthy diet, regular exercise habits, avoidance of tobacco products, and maintenance of a healthy weight. Adherence to lifestyle modification should be regularly assessed at the time of initiation or modification of statin therapy and during monitoring of ongoing therapy.”

Since the publication of the 2013 cholesterol guideline, the US Food and Drug Administration has approved for certain patient groups two monoclonal antibodies, proprotein convertase subtilisin/kexin 9 (PCSK9) inhibitors, which have been shown to dramatically reduce low-density lipoprotein cholesterol levels over and above statin therapy. Additionally, recent publication of the HPS2-THRIVE (examining niacin) and IMPROVE-IT (examining ezetimibe) trials has provided new evidence about the addition of non-statin therapies to statins. The writing committee supports consideration of adding ezetimibe 10 mg daily as the first non-statin agent for many higher-risk patient groups, based upon the benefits in terms of atherosclerotic cardiovascular disease outcomes and demonstrated safety of ezetimibe in patients with acute coronary syndrome treated with ezetimibe-simvastatin versus simvastatin monotherapy. However, they found that there are no clear indications for the routine use of niacin preparations as additional non-statin therapies, and therefore, do not recommend niacin for the situations discussed in the document.

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