New cholesterol-lowering guidelines from the American Heart Association (AHA) and the American College of Cardiology (ACC), as well as several other nationally recognized health and medical organizations, were presented at the 2018 AHA Scientific Sessions held in Chicago, Illinois, November 10-12, 2018, and simultaneously published online in Circulation.1 The guidelines provide new and consistent evidence-based cholesterol-lowering recommendations, including lifestyle interventions, statin and non-statin regimens, risk assessment scores and calculators, and management of specific patient populations.
“The updated guidelines reinforce the importance of healthy living, lifestyle modification, and prevention. They build on the major shift we made in our 2013 cholesterol recommendations to focus on identifying and addressing lifetime risks for cardiovascular disease,” said Ivor Benjamin, MD, FAHA, president of the American Heart Association.2 “Having high cholesterol at any age increases that risk significantly. That’s why it’s so important that even at a young age, people follow a heart-heathy lifestyle and understand and maintain healthy cholesterol levels.”
Recommendations for living a healthy lifestyle, comprised of eating a nutrient-dense diet and the inclusion of regular physical activity, remain a focal point of the 2018 AHA/ACC cholesterol guidelines as they were in the previously published versions. A dietary pattern high in vegetables, fruits, lean proteins, and whole grains, as well as limits on sweets and processed fats, is recommended in the updated guidelines.
Aerobic-type moderate to vigorous physical activity is recommended 3 to 4 days per week at 40 minutes per session. In combination with caloric adjustment, these exercise sessions can be used to reduce body weight in overweight/obese individuals while promoting healthier cholesterol control. For patients with metabolic syndrome (ie, presence of risk factors for atherosclerotic cardiovascular disease (ASCVD), diabetes mellitus, and all-cause death), the recommended lifestyle interventions are particularly indicated.
In addition to lifestyle interventions, statins continue to be the cornerstone of therapy for lipid management. High-intensity, moderate-intensity, and low-intensity statin therapies lower LDL-C levels by ≥50%, 30% to 49%, and <30%, respectively. Recommended statin regimens for each intensity level include:
- High-Intensity Therapy: 80mg atorvastatin (40mg: down titration if intolerable to 80mg) and 20mg rosuvastatin (40mg)
- Moderate-Intensity Therapy: 10mg atorvastatin (20mg) and 10mg rosuvastatin (5mg) and 20mg to 40mg simvastatin or 40mg pravastatin (80mg) and 40mg lovastatin (80mg) and 80mg fluvastatin XL and 40mg fluvastatin BID and pitavastatin
- Low-Intensity Therapy: 10mg simvastatin or 10mg to 20mg pravastatin and 20mg lovastatin and 20mg to 40mg fluvastatin
Ezetimibe is a potentially effective non-statin therapy mentioned in the report, as are bile acid sequestrants. Both therapies have been shown to reduce LDL-C levels by 13% to 20% and 15% to 30%, respectively, according to findings from the committee’s literature review.
While PCSK9 inhibitors are also indicated throughout the guidelines as an effective lipid-lowering non-statin agent, particularly as add-on therapy to a statin regimen, the writing committee noted that little long-term data are available to determine their safety in patients with hypercholesterolemia.
Clinicians are recommended to assess for medication adherence and efficacy at 4 to 12 weeks using a fasting lipid test. Retests for adherence and efficacy should then occur at every 3 to 12 months, depending on the patient.
Coronary Artery Calcium Score
Among patients ≥40 years with an uncertain risk status, calculating the coronary artery calcium (CAC) score is recommended to help with prevention and/or treatment decision-making. Measurement of calcium plaque involves the use of a noninvasive heart scan. Patients with a 0 CAC score are defined as having a generally low cardiovascular disease (CVD) risk for the next 10 years and can delay undergoing cholesterol-lowering medication therapy if they do not smoke and have no other high-risk characteristics.
Conversely, those with a CAC score of ≥100 Agatston units have a 10-year ASCVD risk of ≥7.5%, which is considered a “widely accepted threshold” for starting statins.
Risk Assessment Calculator
In a special report from the AHA/ACC, the risk calculator presented in the 2013 guidelines, which uses population-based formulas, is still recommended for assessing a patient’s 10-year CVD risk.3 The updated guidelines, however, recommend that clinicians speak with their patients about factors that may enhance risk for CVD, including smoking, weight, high blood sugar, metabolic syndrome, inflammation, and hypertension.
Nonmodifiable risk-enhancing factors, including family history and ethnicity, should also be discussed to inform patients and help identify the most appropriate treatment strategy.
Patient Management Groups
High-intensity statin therapy is recommended for patients with clinical ASCVD who are ≥75 years, based on class I evidence. Moderate-intensity statin therapy is recommended for patients with clinical ASCVD only if high-intensity statin therapy is contraindicated, with a goal of a 30% to 49% LDL-C level reduction. In the case of patients with severe hypercholesterolemia (LDL-C ≥190 mg/dL [≥4.9 mmol/L]) between the ages of 20 to 75 years, a maximum-dose approach of statin therapy is recommended. Moderate-intensity statin therapy is indicated in patients aged 40 to 75 years who also have diabetes mellitus, based on class I evidence.
Race- and sex-specific pooled cohort equations can help stratify patients’ ASCVD risk and predict the 10-year risk of the first ASCVD event.
- Grundy SM, Stone NJ, Bailey AL, et al. AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol. Presented at: American Heart Association Scientific Sessions 2018; November 10-12, 2018; Chicago, IL.
- Updated cholesterol guidelines offer more personalized risk assessment, additional treatment options for people at high risk [news release]. Chicago, Ill: AHA/ASA Newsroom. https://newsroom.heart.org/news/updated-cholesterol-guidelines-offer-more-personalized-risk-assessment-additional-treatment-options-for-people-at-the-highest-risk. November 10, 2018. Accessed November 12, 2018.
- Lloyd-Jones DM, Braun LT, Ndumele CE, et al. Use of risk assessment tools to guide decision-making in the primary prevention of atherosclerotic cardiovascular disease: a special report from the American Heart Association and American College of Cardiology [published online November 10, 2018]. Circulation. doi: 10.1161/CIR.0000000000000638