What are the American Heart Association (AHA) guidelines for managing cholesterol?

From the Guidelines

The American Heart Association (AHA) guidelines for managing cholesterol prioritize assessing cardiovascular risk and using appropriate interventions based on risk level, with a focus on lifestyle modifications and statin therapy for high-risk individuals, as outlined in the 2018 AHA/ACC/Multisociety Cholesterol Guideline 1.

Key Recommendations

• For primary prevention, lifestyle modifications are recommended for all individuals, including a heart-healthy diet, regular physical activity, weight management, and smoking cessation.
• Statin therapy is recommended for high-risk individuals, including those with LDL cholesterol ≥190 mg/dL, diabetes aged 40-75 years, or those with calculated 10-year ASCVD risk ≥7.5% 1.
• For secondary prevention (those with existing cardiovascular disease), high-intensity statins like atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily are recommended to achieve at least a 50% reduction in LDL cholesterol 1.
• For very high-risk patients not achieving adequate LDL reduction with statins alone, additional therapies like ezetimibe (10 mg daily) or PCSK9 inhibitors (evolocumab or alirocumab) may be added, as supported by recent studies such as REDUCE-IT 1.

Risk Assessment and Monitoring

• The guidelines emphasize regular monitoring of lipid levels and adjusting therapy as needed, with LDL targets generally below 70 mg/dL for secondary prevention 1.
• The use of risk-enhancing factors, such as elevated triglycerides, and coronary artery calcium testing can assist in the decision to use statin therapy in primary prevention 1.

Recent Updates and Considerations

• The 2021 ACC Expert Consensus Decision Pathway on the Management of ASCVD Risk Reduction in Patients with Persistent Hypertriglyceridemia provides updated guidance on the management of patients with elevated triglycerides, including the use of icosapent ethyl (IPE) for ASCVD risk reduction in specific patient populations 1.
• The guidelines prioritize a heart-healthy lifestyle and statin therapy as the foundation of cholesterol management, with additional therapies considered for high-risk patients or those not achieving adequate LDL reduction with statins alone.

From the Research

AHA Guidelines for Managing Cholesterol

The American Heart Association (AHA) guidelines for managing cholesterol emphasize the importance of reducing low-density lipoprotein (LDL) cholesterol levels to decrease the risk of atherosclerotic cardiovascular disease (ASCVD) 2. The guidelines recommend statin therapy as the first-line treatment for primary and secondary prevention of ASCVD.

Key Recommendations

• Patients with primary prevention are divided into those who are at low, borderline, intermediate, and high risk based on the ASCVD risk estimator 2.
• The guidelines consider a wider range of factors, including "risk enhancers" such as premature family history of ASCVD, persistently high LDL-C, and chronic kidney disease (CKD) 2.
• For persons with known ASCVD, a distinction is made for those who are at "very high risk" based on having had two major ASCVD events or one major event and two or more other high-risk conditions 2.
• Ezetimibe is recommended as the key non-statin to be added if the LDL-C still remains ≥ 70 mg/dL for all ASCVD patients, and in those who are at "very high risk", further consideration for using a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor is recommended 2.

Treatment Options

• Statins are the mainstay of medical cardiovascular risk reduction because of their effectiveness in decreasing LDL-C 3.
• PCSK9 inhibitors, such as alirocumab and evolocumab, have been approved for treating hyperlipidemia in patients who are intolerant to or have limited benefit from statins 4, 3, 5, 6.
• Ezetimibe, a cholesterol absorption inhibitor, can be used in combination with statin therapy to achieve additional LDL-C reduction and decrease ASCVD risk 4.

Benefits of Treatment

• Statin therapy has been proven to effectively reduce the risk of ASCVD and is recommended as a first-line therapy for the primary and secondary prevention of ASCVD 4.
• PCSK9 inhibitors have been shown to significantly decrease serum LDL-C levels and thereby ASCVD risks when added to maximally tolerated statin therapy 4, 5.
• Ezetimibe has been shown to lead to additional LDL-C reduction and decreased ASCVD risk when added to statin therapy 4.