2018 Cholesterol Guidelines: Key Points

Cardiovascular disease is the leading cause of death in the United States. Cholesterol anomaly, or dyslipidemia, is a major contributor to atherosclerosis morbidity and mortality. Multi-society new cholesterol guidelines were recently published. They were contributed and endorsed by ACC, AHA, ADA, and NLA, among other national associations. You can find below the key recommendations published in the journal of Circulation, November 2018.

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CIRCULATION

Cholesterol GUIDELINES

November 2018

  1. In all individuals, emphasize a heart-healthy lifestyle across the life course. A healthy lifestyle reduces ASCVD risk at all ages. In younger individuals, healthy lifestyle can reduce development of risk factors (RFs) and is the foundation of ASCVD risk reduction.

    • In young adults 20-40 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.

  2. In patients with clinical ASCVD, reduce LDLc with high-intensity statin therapy or maximally tolerated statin therapy.

    • The more LDLc is reduced on statin therapy, the greater will be subsequent risk reduction.

    • Use a maximally tolerated statin to lower LDLc levels by ≥50%.

    • High-intensity Statins are Atorvastatin 40-80 mg/day or Rosuvastatin 20-40 mg/day

  3. In very high-risk ASCVD, use a LDLc threshold of 70 mg/dL to consider addition of non-statins to statin therapy. Very high-risk includes:

    • A history of multiple major ASCVD events or

    • 1 major ASCVD event + multiple high-risk conditions.

    • In very high-risk ASCVD patients, it is reasonable to add ezetimibe to maximally tolerated statin therapy when the LDLc level remains ≥70 mg/dL

    • In patients at very high risk whose LDLc level remains ≥70 mg/dL on maximally tolerated statin + 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 list prices.

  4. In patients with severe primary hypercholesterolemia (LDLc ≥190 mg/dL) without calculating 10-year ASCVD risk:

    • Begin high-intensity statin therapy without calculating 10-year ASCVD risk. If the LDLc level remains ≥100 mg/dL, adding ezetimibe is reasonable.

    • If the LDLc level on statin + 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 low at mid-2018 list prices.

  5. In patients 40-75 years of age with DM and LDLc ≥70 mg/dL, start moderate-intensity statin therapy without calculating 10-year ASCVD risk.

    • In patients with DM at higher risk, especially those with multiple RFs or those 50-75 years of age, it is reasonable to use a high-intensity statin to reduce the LDLc level by ≥50%.

    • High-intensity Statins are Atorvastatin 40-80 mg/day or Rosuvastatin 20-40 mg/day

  6. In adults 40-75 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 (RFs):

      • Cigarette smoking

      • Elevated blood pressure

      • LDLc

      • A1c

      • And calculated 10-year risk [10YR] of ASCVD

    • The presence of risk-enhancing factors (REFs)

    • 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.

  7. In adults 40-75 years of age without DM and with LDLc ≥70 mg/dL, at a 10YR ≥7.5%, start a moderate-intensity statin if a discussion of treatment options favors statin therapy.

    • If risk status is uncertain, consider using (coronary artery calcium) CAC score to improve specificity.

    • If statins are indicated:

      • Reduce LDLc levels by ≥30%

      • And if 10YR is ≥20% (high risk), reduce LDLc levels by ≥50%.

  8. In adults 40-75 years of age without DM and 10YR of 7.5-20% (intermediate risk), risk-enhancing factors (REFs) favor initiation of statin therapy. REFs include:

    • FHX of premature ASCVD

    • Persistently elevated LDLc ≥160 mg/dL

    • Presence of comorbidities:

      • Metabolic syndrome

      • Chronic kidney disease

      • History of preeclampsia

      • Premature menopause (age <40 years)

      • Chronic inflammatory disorders (e.g., RA, Lup, Psor, or HIV)

    • High-risk ethnic groups (e.g. South Asian)

    • Persistently elevated TGs ≥175 mg/dL

    • And, if measured in selected individuals:

      • Apo B ≥130 mg/dL

      • hsCRP ≥2.0 mg/L

      • ABI <0.9 and

      • Lp(a) ≥50 mg/dL, especially at higher values

    • REFs may favor statin therapy in patients at 10YR of 5-7.5% (borderline risk).

  9. In adults 40-75 years of age without DM and with LDLc 70-90 mg/dL, at a 10YR of 7.5-20%, if a decision about statin therapy is uncertain, consider measuring CAC.

    • If CAC is zero, treatment with statin therapy may be withheld or delayed, except in:

      • Cigarette smokers

      • Those with DM

      • And those with a strong FHX of premature ASCVD.

    • CAC score of 1-99 favors 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.

  10. Assess adherence and percentage response to LDLc–lowering medications and lifestyle changes with repeat lipid measurement 4-12 weeks after statin initiation or dose adjustment, repeated every 3-12 months as needed.

    • Define responses to lifestyle and statin therapy by percentage reductions in LDLc levels compared with baseline.

    • In ASCVD patients at very high-risk, triggers for adding non-statin drug therapy are defined by threshold LDLc levels ≥70 mg/dL on maximal statin therapy.

 
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