The American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE) authorities have updated their clinical practice guidelines for dyslipidemia management and atherosclerosis prevention.

The 2017 update emphasizes a new cardiovascular disease (CVD) risk category: “The Extreme Risk” and optimal lipid management goals.

The new "Extreme Risk" category includes the following group of patients:

• Those with a progressive CVD,
• Those who have unstable angina, after achieving an LDL cholesterol level <70mg/dL
• Those With CVD, Diabetes mellitus, chronic kidney disease (stages 3 or 4), or Heterozygous familial hypercholesterolemia (HeFH)
• Men ≤55 years old (or) women ≤65 years old -with a premature CVD history.

And the Treatment goals proposed for them include:

• LDL cholesterol <55mg/dL,
• Non-HDL cholesterol <80mg/dL, and
• Apolipoprotein B (ApoB) <70mg/dL.

Recommended therapy for this sub-group:

• Intensive high-dose Statin therapy or
• Statins combined with Ezetimibe or PCSK9 inhibitors.

The data from the Improved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT) Clinical trial has helped drive some of the modifications in the new guidelines. IMPROVE-IT was intended to determine whether reducing LDL in addition to aggressive statin therapy with ezetimibe would improve outcomes.

The IMPROVE-IT trial revealed the following:

• Inclusion of ezetimibe to a statin therapy decreased LDL-Cholesterol by about 24.2%. (While the statin-alone group achieved LDL-C of 69.9 mg/dL, statin plus ezetimibe achieved an average LDL-C of 53 mg/dL.) Also, there were notable reductions in the ASCVD end points in the statin-plus-ezetimibe group
• Combining simvastatin and ezetimibe, which reduces cholesterol absorption from the gastrointestinal tract, resulting in a significantly lower CVD risk than that observed with statin monotherapy.
• Patients treated with statins reached the lowest LDL-Cholesterol levels and had the best outcomes.

Highlights of the 2017 AACE guidelines:

• The importance of evaluating women for CVD utilizing devices that determine the 10-year risk for a coronary event.
• The Demand for diagnosing and enduring children and adolescents with dyslipidemia at the earliest possible to attempt to reduce the long-term risk for an adult cardiovascular event.
• Optimal disease management- For Clinicians to Improve CVD detection and providing vital support. (Since these are valid guidelines based on clinical evidence)
• Combining ezetimibe and PCSK9 inhibitors in treatment plans for CVD patients who are unable to reach LDL cholesterol goals with statin therapy.
• The Conception of such an 'Extreme Risk' category is potentially significant because It supports the need for more aggressive LDL and non-HDL reduction in patients with progressive or premature ASCVD, diabetes, Chronic kidney disease (stage 3 or 4), or HeFH.
• Lower is better in Extreme-risk patients. Lower levels of LDL-Cholesterol can be easily achieved via Proprotein convertase subtilisin/Kexin type-9 (PCSK9) inhibitors.

This update addresses a wide range of disease stages with high intense treatment and more aggressive intervention. This is expected to improve diagnosis and support physicians to ensure that their patients receive appropriate workup and optimal disease management to reduce further CVD morbidity and mortality in these Extreme Risk patient groups.