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

AHA/ACC Cholesterol Management Guidelines

The 2018 AHA/ACC cholesterol management guidelines recommend using high-intensity statin therapy or maximally tolerated statin therapy to reduce LDL-C by ≥50% in patients with clinical ASCVD, with additional non-statin therapies for very high-risk patients whose LDL-C remains ≥70 mg/dL despite maximal statin therapy. 1

Core Recommendations by Patient Category

For All Individuals

• Emphasize heart-healthy lifestyle across the lifespan as the foundation of ASCVD prevention 1
• Focus on dietary patterns rich in vegetables, fruits, whole grains, and low in saturated/trans fats 2
• Replacing saturated fats with polyunsaturated fats can reduce CVD risk by approximately 30% 2

For Secondary Prevention (Established ASCVD)

1. High-intensity statin therapy is first-line treatment to reduce LDL-C by ≥50% 1

   • Examples: atorvastatin 40-80 mg, rosuvastatin 20-40 mg daily

2. For very high-risk ASCVD patients (multiple major ASCVD events or one major event plus multiple high-risk conditions):

   • Use LDL-C threshold of 70 mg/dL (1.8 mmol/L) to consider non-statin add-on therapy 1
   • If LDL-C remains ≥70 mg/dL on maximally tolerated statin, add ezetimibe 1
   • If LDL-C still remains ≥70 mg/dL after statin plus ezetimibe, consider adding PCSK9 inhibitor 1

For Primary Prevention

Severe Hypercholesterolemia (LDL-C ≥190 mg/dL)

• Begin high-intensity statin therapy without calculating 10-year ASCVD risk 1
• If LDL-C remains ≥100 mg/dL, consider adding ezetimibe 1
• For patients with multiple risk factors and persistent LDL-C ≥100 mg/dL despite statin plus ezetimibe, consider PCSK9 inhibitor 1

Diabetes Mellitus (Age 40-75)

• Start moderate-intensity statin therapy when LDL-C ≥70 mg/dL without calculating 10-year risk 1
• For higher-risk diabetic patients (multiple risk factors or age 50-75), use high-intensity statin therapy 1

Primary Prevention (Without Diabetes or Severe Hypercholesterolemia)

1. Calculate 10-year ASCVD risk using Pooled Cohort Equations 1
2. Categorize patients into risk groups:
   • Low risk (<5%): Emphasize lifestyle
   • Borderline risk (5% to <7.5%): Consider statin for risk enhancers
   • Intermediate risk (7.5% to <20%): Initiate statin therapy; consider CAC score if decision uncertain
   • High risk (≥20%): Start high-intensity statin therapy 1

Risk-Enhancing Factors to Consider

• Family history of premature ASCVD
• Persistently elevated LDL-C ≥160 mg/dL
• Metabolic syndrome
• Chronic kidney disease
• Chronic inflammatory conditions
• History of premature menopause or preeclampsia
• High-risk race/ethnicities
• Elevated triglycerides 1

Monitoring and Follow-up

• Non-fasting lipid measurements are acceptable for monitoring 1
• Check lipid panel 4-12 weeks after initiating or adjusting therapy to assess response and adherence 1
• Monitor for statin-associated side effects, particularly muscle symptoms 1
• For patients with statin-associated side effects, consider lower doses, alternate-day dosing, or different statin options 1

Important Considerations

• Approximately 60% of high-risk patients have residual dyslipidemia despite achieving total cholesterol targets 3
• The 2018 guidelines place greater emphasis on percentage LDL-C reduction as a treatment goal compared to the 2013 guidelines 1
• Statin therapy may increase risk for incident diabetes in susceptible individuals, but this should not be cause for discontinuation given the greater ASCVD risk reduction benefits 1

The 2018 AHA/ACC guidelines represent a significant evolution from the 2013 guidelines, with greater emphasis on risk stratification, LDL-C reduction targets, and the selective use of non-statin therapies for high-risk patients with inadequate response to statins alone.