Structured Treatment Guideline for ASCVD Patients

(Atherosclerotic Cardiovascular Disease)

  1. General Principles for All ASCVD Patients

 Lifestyle modifications (Class I recommendation):

  • Smoking cessation
  • Heart-healthy diet
  • Cardiovascular physical activity
  • Weight reduction, if overweight

 Blood pressure control:

  • Target SBP < 140 mmHg, ideally < 130 mmHg if tolerated

Antiplatelet therapy:

  • Long-term antiplatelet treatment (e.g., aspirin) unless contraindicated
  1. Lipid-Lowering Therapy – Stepwise Approach

 Initial Assessment

  • Confirm very high cardiovascular risk
  • Determine baseline LDL-C

 Step 1: First-Line Therapy

  • Start high-intensity statin therapy
  • Combine with ezetimibe if LDL-C target not achieved
  • Target LDL-C < 70 mg/dL (< 1.8 mmol/L)
  • Goal: ≥50% LDL-C reduction from baseline

 Step 2: Intensified Therapy

If LDL-C remains above 70 mg/dL or disease is progressing:

  • Intensify therapy to reach LDL-C < 55 mg/dL (< 1.4 mmol/L)
  • Consider adding a PCSK9 inhibitor
  1. Special Considerations for High-Risk Patients

Patients with:

  • Recent cardiovascular event
  • Progressive ASCVD despite therapy
  • ASCVD + diabetes mellitus

 Have especially high recurrence risk and may need more aggressive approaches.

  1. Optional Add-On Therapies in Select Patients (if disease progresses despite optimal LDL-C lowering)

 Consider:

  • Dual antithrombotic therapy (e.g., aspirin + low-dose rivaroxaban)
  • Icosapent ethyl (omega-3 fatty acid derivative)
  • Anti-inflammatory therapy (e.g., low-dose colchicine)
  1. Follow-Up and Monitoring
  • Reassess lipid panel 4–12 weeks after therapy adjustment
  • Monitor for side effects and adherence
  • Regularly reassess cardiovascular symptoms, BP, glucose, and kidney function

 

Risk Assessment and Risk Management in Patients with Known Atherosclerotic Cardiovascular Disease (ASCVD)

Patients with established ASCVD have a very high cardiovascular risk if left untreated.
Therefore, the LDL-C target levels are significantly lower for these individuals.
The risk of a cardiovascular event can vary widely.
Patients who have had a recent event, progressive vascular disease, or diabetes mellitus are at particularly high risk of a recurrence.

All patients are advised to:

  • Stop smoking
  • Adopt a healthy lifestyle, including:
    • A heart-healthy diet
    • Regular cardiovascular exercise
    • Weight reduction, if necessary

Systolic blood pressure should be reduced to below 140 mmHg, and if tolerated, ideally to below 130 mmHg.

An intensified lipid-lowering therapy aiming for a >50% reduction in LDL-C from baseline is recommended.

An LDL-C target of < 70 mg/dL (< 1.8 mmol/L) should be pursued from baseline.
In addition, antiplatelet therapy should be administered.

In the second step, further intensification of lipid-lowering therapy is recommended,
with a target of LDL-C < 55 mg/dL (< 1.4 mmol/L).

Despite maximal therapy, some patients continue to have progressive cardiovascular disease.
In such cases, less well-established treatments may be considered, such as:

  • Dual antithrombotic therapy
  • Icosapent ethyl
  • Anti-inflammatory therapy with colchicine