Management of Blood Cholesterol : 2018 ACC/AHA Guideline

The 2018 ACC/AHA guideline updates the 2013 guideline and it emphasizes reducing the risk of atherosclerotic cardiovascular disease (ASCVD) through cholesterol management. It also stresses a more intensive approach based on recent controlled studies and expert consensus. The AHA/ACC 2018 guideline on the management of blood cholesterol, has been endorsed by at least 10 other medical societies. It has been published in the Journal of the American College of Cardiology and in Circulation to coincide with their grand unveiling at the AHA sessions.

The new recommendations, advocate for more aggressive treatment with statin therapy in specific instances, while also encouraging a more personalized approach that addresses a heart-healthy lifestyle and better collaboration in decision-making between clinicians and their patients.

Key Recommendations are

• In all individuals, emphasize a heart-healthy lifestyle across the life course. A healthy lifestyle reduces ASCVD risk at all ages. In younger individuals, a healthy lifestyle can reduce the development of risk factors and is the foundation of ASCVD risk reduction. In young adults 20 to 39 years of age, an assessment of lifetime risk facilitates the clinician-patient risk discussion and emphasizes intensive lifestyle efforts. In all age groups, lifestyle therapy is the primary intervention for metabolic syndrome.


• In patients with clinical ASCVD, reduce low-density lipoprotein cholesterol (LDL-C) with high-intensity statins or maximally tolerated statins to decrease ASCVD risk. Greater LDL-C reductions on statin therapy, leading to lower LDL-C levels, lower significant risk. Use a maximally tolerated statin to reduce LDL-C levels by ≥50%.


• In very high-risk ASCVD, use an LDL-cholesterol threshold of 70 mg/dl (1.8 mmol/L) to consider the addition of nonstatins to statins. In very high-risk ASCVD patients, it is reasonable to add ezetimibe to maximally tolerated statin therapy when the LDL-C level remains ≥70 mg/dl (≥1.8 mmol/L). In patients at very high risk whose LDL-C level remains ≥70 mg/dl on a maximally tolerated statin and ezetimibe therapy, adding a PCSK9 inhibitor is reasonable, although the long-term safety (>3 years) is uncertain and cost-effectiveness is low at mid-2018 prices.


• In patients with severe primary hypercholesterolemia (LDL-C level ≥190 mg/dl [≥4.9 mmol/L]) without calculating 10-year ASCVD risk, begin high-intensity statin therapy. If the LDL-C level remains ≥100 mg/dl, adding ezetimibe is reasonable. If the LDL-cholesterol level on statin plus ezetimibe remains ≥100 mg/dl and the patient has multiple factors that increase subsequent risk of ASCVD events, a PCSK9 inhibitor may be considered, although the long-term safety (>3 years) is uncertain and economic value is uncertain at mid-2018 prices.


• In patients 40 to 75 years of age with diabetes mellitus and an LDL-cholesterol level of ≥70 mg/dl, start moderate-intensity statins without calculating 10-year ASCVD risk. In patients with diabetes mellitus at higher risk, especially those with multiple risk factors or those 50 to 75 years of age, it is reasonable to use a high-intensity statin to reduce the LDL-cholesterol level by ≥50%.


• In adults, 40 to 75 years of age evaluated for primary ASCVD prevention, have a clinician-patient risk discussion before starting statin therapy. Risk discussion should include a review of major risk factors (e.g., cigarette smoking, elevated blood pressure, LDL-C, haemoglobin A1c [if indicated], and calculated 10-year risk of ASCVD); the presence of risk-enhancing factors (see #8); the potential benefits of lifestyle and statin therapies; the potential for adverse effects and drug-drug interactions; consideration of costs of statin therapy; and patient preferences and values in shared decision-making.


• In adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dl (≥1.8 mmol/L), at a 10-year ASCVD risk of ≥7.5%, start a moderate-intensity statin if a discussion of treatment options favours statin therapy. Risk-enhancing factors favour statin therapy (see #8). If risk status is uncertain, consider using CAC to improve specificity (see #9). If statins are indicated, reduce LDL-C levels by ≥30%, and if a 10-year risk is ≥20%, reduce LDL-C levels by ≥50%.


• In adults 40 to 75 years of age without diabetes mellitus and 10-year risk of 5%-19.9%, risk-enhancing factors favour initiation of statin therapy. Risk-enhancing factors include family history of premature ASCVD; persistently elevated LDL-C levels ≥160 mg/dl (≥4.1 mmol/L); metabolic syndrome; chronic kidney disease; history of preeclampsia or premature menopause (age <40 years); chronic inflammatory disorders (e.g., rheumatoid arthritis, psoriasis, or chronic HIV); high-risk ethnic groups (e.g., South Asian); persistent elevations of triglycerides ≥175 mg/dl (≥1.97 mmol/L); and, if measured in selected individuals, apolipoprotein B ≥130 mg/dl or ≥2500 nmol/L, high-sensitivity C-reactive protein ≥2.0 mg/L (190 nmol/L), ABI <0.9, and lipoprotein (a) ≥50 mg/dl or 125 nmol/L, especially at higher values of lipoprotein (a).


• In adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dl-89 mg/dl (≥1.8-4.9 mmol/L), at a 10-year ASCVD risk of ≥7.5%-19.9%, if a decision about statin therapy is uncertain, consider measuring CAC. If the CAC score is zero, treatment with statin therapy may be withheld or delayed, except in cigarette smokers, those with diabetes mellitus, and those with a strong family history of premature ASCVD. A CAC score of 1-99 favours statin therapy, especially in those >55 years of age. For any patient, if the CAC score is ≥100 Agatston units or ≥75th percentile, statin therapy is indicated unless otherwise deferred by the outcome of clinician-patient risk discussion.


• Assess adherence and percentage response to LDL-C–lowering medications and lifestyle changes with repeat lipid measurement 4 to 12 weeks after statin initiation or dose adjustment, repeated every 3 to 12 months as needed. Define responses to lifestyle and statin therapy by percentage reductions in LDL-C levels compared with baseline. In ASCVD patients at very high-risk, triggers for adding nonstatin drugs are defined by threshold LDL-C levels ≥70 mg/dl (≥1.8 mmol/L) on maximal statin therapy.

"Our goal with these new guidelines is to not only reduce heart attacks and stroke but to also reduce the need for angioplasties and the incidence of peripheral arterial disease too, which traditionally haven’t received as much attention from clinicians as life-threatening acute vascular events,” says Chiadi Ndumele, M.D., M.H.S., the Robert E. Meyerhoff Assistant Professor at the Johns Hopkins University School of Medicine. A peripheral arterial disease is narrowing or blocking of blood vessels from the heart to the legs. About 8.5 million people in the U.S. have the condition, which can make it painful to walk.

For further reference log on to: doi/suppl/10.1161/CIR.0000000000000625