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Guidelines on Cholesterol Management: What You Need to Know

Guidelines from the American Heart Association and the American College of Cardiology were released on November 10, 2018. Drs. Roger Blumenthal and Chiadi Ndumele were on the writing committee.

The guidelines recommended that more adults discuss with their health care provider whether they should consider taking a statin medication, even if they have average cholesterol levels and have never had a heart attack, stroke, or cardiac event.

The higher risk groups include:
  • Adults with existing heart disease or prior stroke
  • Adults with LDL “bad” cholesterol levels of 190 mg/dL or above
  • Adults age 40 to 75 who have diabetes
  • Adults whose age, blood pressure, cholesterol and smoking behavior give them an estimated risk of heart attack or stroke higher than 7.5 percent in the next 10 years

The highest risk individuals should aim to get their LDL-cholesterol < 70mg/dL through lifestyle improvements and statin therapy. Consideration can also be given to adding ezetimibe or a PCSK9 inhibitor to the medical regimen of certain very high-risk adults.

Manage Your Cholesterol

Managing cholesterol a key element in reducing your risk of heart attack and stroke.

  • High levels of LDL cholesterol can build up as plaque inside of blood vessels and raise the risk of a heart attack or a stroke. 
  • Lifestyle changes are the most important steps to lower cholesterol and therefore lower the risk of heart attack and stroke. Those include a healthy diet (for instance the DASH diet or the Mediterranean diet), regular physical activity, managing your weight and not smoking.

Ten Takeaways from the 2018 Guidelines: 

  1. Emphasize a heart-healthy lifestyle at all ages. Better dietary and exercise habits are the cornerstone of prevention.
  2. In patients with atherosclerotic cardiovascular disease (ASCVD), aim to reduce LDL-Cholesterol with a high intensity statin or maximally tolerated statin.
  3. In very high-risk ASCVD patients, use a threshold of 70 mg/dL to consider addition of a nonstatin (ezetimibe or PCSK9 inhibitor) to statin therapy.
  4. If a patient has severe primary hypercholesterolemia (LDL-C > 190 mg/dL) or diabetes, begin a high intensity statin even if there are no other risk factors. If the LDL-C remains consistently > 100 mg/dL, ezetimibe or a PCSK9 inhibitor can be added.
  5. All patients age 40-75 with diabetes, and an LDL-C >70 mg/dL, a moderate intensity statin can be started even if there are no other cardiac risk factors.
  6. A clinician-patient risk discussion should be undertaken before starting a statin.
  7. If a person has an estimated 10-year ASCVD risk of at least 7.5%, a moderate-intensity statin can be started if the discussion of treatment options favors statin therapy.
  8. In adults, age 40-75 years of age and a 10-year risk of 5% to 19.9%, the presence of risk enhancing factors favor starting a statin in persons at borderline or intermediate risk:
    • Strong family history of premature ASCVD;
    • Persistently elevated LDL-C > 160;
    •  Metabolic Syndrome (Pre-diabetes);
    • Chronic Kidney Disease;
    • History of pre-eclampsia or early menopause;
    • Chronic inflammatory disorders such as rheumatoid arthritis, lupus, advanced psoriasis, HIV infection;
    • South Asian ethnicity;
    • Persistent elevations of triglycerides > 175;
    • Lipoprotein (a) >50 mg/dL or 125 mol/L
  9. If a decision about statin therapy remains uncertain if an adult has an estimated 10-year risk of 5-20%, a coronary artery calcium scan is the best tie-breaker.
  10. To assess adherence and percentage response to LDL-C lowering medications and lifestyle changes, a lipid profile should be repeated 4 to 12 weeks after statin initiation or dose adjustment and then every 6 to 12 months as needed.