What are the newest guidelines for managing high cholesterol?

Newest Guidelines on Cholesterol Management

The 2018 AHA/ACC/Multi-Society Cholesterol Guidelines recommend a risk-based approach to cholesterol management, with statins as the cornerstone of therapy, supplemented by ezetimibe or PCSK9 inhibitors for very high-risk patients, and emphasize lifestyle modifications as foundational for all patients. 1

Risk Assessment and Screening

• Complete lipoprotein profile (total cholesterol, LDL-C, HDL-C, triglycerides) is the preferred screening method for assessing cardiovascular disease risk, ideally using fasting samples, though non-fasting measurements are now acceptable for initial screening 1
• Screening is recommended for all patients 20 years or older and should be repeated every 5 years 1
• Risk assessment includes calculating the 10-year ASCVD risk using the Pooled Cohort Equations for patients with multiple risk factors 1
• Coronary artery calcium (CAC) scoring is now recommended as a decision-making tool for patients with intermediate risk when the decision to start statin therapy is uncertain 1

Treatment Categories and Goals

• The 2018 guidelines identify four major statin benefit groups 1:

  1. Patients with clinical ASCVD (secondary prevention)
  2. Patients with LDL-C ≥190 mg/dL (≥4.9 mmol/L)
  3. Patients with diabetes aged 40-75 years with LDL-C 70-189 mg/dL (1.8-4.9 mmol/L)
  4. Patients without diabetes aged 40-75 years with LDL-C 70-189 mg/dL (1.8-4.9 mmol/L) and 10-year ASCVD risk ≥7.5%

• Unlike previous guidelines, the 2018 guidelines no longer focus on specific LDL-C targets but instead emphasize percentage reduction in LDL-C based on risk category and statin intensity 1

Secondary Prevention Recommendations

• For patients with clinical ASCVD, high-intensity or maximally tolerated statin therapy is recommended to reduce LDL-C levels by ≥50% 1
• For very high-risk ASCVD patients (multiple major ASCVD events or one major event with multiple high-risk conditions), adding non-statin therapy is reasonable if LDL-C remains ≥70 mg/dL (1.8 mmol/L) despite maximally tolerated statin therapy 1
• Ezetimibe should be considered first as add-on therapy, followed by PCSK9 inhibitors if needed 1

Primary Prevention Recommendations

• For primary prevention, a clinician-patient risk discussion is strongly recommended before initiating statin therapy 1
• For patients with severe hypercholesterolemia (LDL-C ≥190 mg/dL), high-intensity statin therapy is recommended without risk calculation 1
• For patients with diabetes aged 40-75 years, moderate-intensity statin therapy is recommended, with high-intensity statin considered for those with multiple risk factors 1
• For patients without diabetes aged 40-75 years with LDL-C 70-189 mg/dL and 10-year ASCVD risk ≥7.5%, moderate-intensity statin therapy is recommended after clinician-patient discussion 1

Lifestyle Modifications

• Lifestyle therapy remains foundational for all patients and includes 1, 2:

  • Heart-healthy diet emphasizing fruits, vegetables, whole grains, lean proteins
  • Regular physical activity (30-60 minutes of moderate-intensity activity most days)
  • Weight management
  • Smoking cessation

• The current guidelines recommend one diet for all patients rather than the previous two-step approach 1

• Plant sterols/stanols are now encouraged as a therapeutic dietary option to lower LDL-C levels 1

Special Considerations

• For patients with low HDL-C, lifestyle modifications including regular aerobic exercise, smoking cessation, and dietary changes are first-line interventions 2
• Pharmacological options for low HDL-C include niacin (increases HDL by 15-35%) and fibrates (increases HDL by 15-25%), though these should be used cautiously and primarily when combined with other lipid abnormalities 2, 3
• For patients with elevated triglycerides (≥200 mg/dL), treatment beyond LDL lowering should be considered 1, 4

Monitoring and Follow-up

• The 2018 guidelines emphasize monitoring percentage reduction in LDL-C rather than achieving specific targets 1
• Follow-up lipid testing is recommended to assess adherence to therapy and adequacy of LDL-C reduction 1
• Non-fasting lipid measurements are now acceptable for monitoring 1

Common Pitfalls and Caveats

• Overreliance on calculated LDL-C using the Friedewald formula can lead to inaccuracies, especially with low LDL-C levels (<70 mg/dL); direct LDL-C measurement is recommended in these cases 1
• Combination therapy with statins and fibrates increases the risk of myositis; lower statin doses should be used with this combination 2, 3
• Dietary cholesterol restrictions have been de-emphasized in recent guidelines, as evidence does not strongly support a direct link between dietary cholesterol and cardiovascular disease 5
• Many patients fail to achieve optimal lipid control due to inadequate implementation of lifestyle modifications, which should remain a cornerstone of therapy even when medications are prescribed 6