What are the guidelines for managing high cholesterol?

Current Cholesterol Management Guidelines

The 2018 AHA/ACC guidelines recommend a comprehensive approach to cholesterol management based on individual cardiovascular risk assessment, with specific LDL-C goals and treatment strategies tailored to risk categories. 1

Risk Assessment and Screening

• A complete lipoprotein profile (total cholesterol, LDL-C, HDL-C, and triglycerides) is recommended for screening all adults 20 years and older, repeated every 5 years 1, 2
• Risk assessment should incorporate multiple risk factors beyond lipid levels, including age, gender, diabetes, elevated blood pressure, family history, and smoking status 1
• For patients with borderline or intermediate risk (7.5%-19.9% 10-year ASCVD risk), risk-enhancing factors should be considered, including family history of premature ASCVD, persistently elevated LDL-C ≥160 mg/dL, metabolic syndrome, chronic kidney disease, and inflammatory disorders 1, 2
• Coronary artery calcium (CAC) scoring may be used to refine risk assessment in intermediate-risk patients when the decision about statin therapy is uncertain 1

Treatment Goals

• For very high-risk patients (those with ASCVD or ASCVD risk equivalents): LDL-C goal <70 mg/dL 1, 2
• For high-risk patients: LDL-C goal <100 mg/dL 1, 2
• For moderately high-risk patients: LDL-C goal <130 mg/dL, with an optional goal of <100 mg/dL 2
• For patients with diabetes: LDL-C goal <100 mg/dL 1
• Optimal HDL-C levels are >40 mg/dL (>50 mg/dL for women) 1, 2
• Desirable triglyceride levels are <150 mg/dL 1, 2

Therapeutic Lifestyle Changes

• Therapeutic lifestyle changes remain the foundation for all cholesterol management strategies and should be implemented before or concurrently with medication 2
• Diet recommendations include:
  • Reduced intake of saturated fats (<7-10% of calories) and trans fats 2, 3
  • Increased consumption of unsaturated fats (15-20% of calories) 3
  • Increased intake of plant sterols/stanols and viscous fiber 2, 3
  • Emphasis on vegetables, fruits, whole grains, low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils, and nuts 2
• Regular physical activity, weight management, smoking cessation, and moderate alcohol consumption (if applicable) are recommended 2, 3
• Combined lifestyle interventions (healthy diet, weight loss, and physical activity) can increase HDL-C by 10-13% 3

Pharmacological Therapy

Statin Therapy

• Statins are the first-line pharmacological therapy for most patients requiring medication 2, 4
• High-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) is recommended for:
  • Patients with clinical ASCVD 1, 2
  • Patients with LDL-C ≥190 mg/dL 5, 2
  • Very high-risk patients 1, 2
• Moderate-intensity statin therapy is recommended for:
  • Patients aged 40-75 years with diabetes and LDL-C 70-189 mg/dL 2
  • Patients aged 40-75 years without diabetes with 10-year ASCVD risk ≥7.5% 1, 2
• Treatment response should be assessed 4-12 weeks after statin initiation or dose adjustment 1, 4
• For high-risk patients, LDL-C reduction should be ≥50%; for moderate-risk patients, ≥30% 1, 5

Non-Statin Therapies

• For very high-risk ASCVD patients whose LDL-C remains ≥70 mg/dL on maximally tolerated statin therapy, adding ezetimibe is recommended 5, 2
• For patients at very high risk whose LDL-C remains ≥70 mg/dL despite statin and ezetimibe therapy, adding a PCSK9 inhibitor is reasonable 2, 6
• For patients with severe hypertriglyceridemia, fibrates may be considered 1, 2
• Combination therapy should be used cautiously due to increased risk of adverse effects, particularly myopathy with statin-fibrate combinations 2, 7

Special Populations

Patients with Diabetes

• Patients with diabetes are considered high risk and should receive statin therapy regardless of baseline LDL-C 1, 2
• Glycemic control is the first priority for triglyceride management in diabetic patients 1
• For combined hyperlipidemia in diabetic patients, improved glycemic control plus high-dose statin is the first choice 1

Patients with Familial Hypercholesterolemia

• Patients with severe hypercholesterolemia (LDL-C ≥190 mg/dL) should receive high-intensity statin therapy without calculating 10-year ASCVD risk 5, 2
• Genetic testing and cascade screening of family members should be considered for suspected FH 5
• For pediatric patients with FH, statin therapy may be considered from age 10 years 8

Monitoring and Follow-up

• Lipid levels should be measured annually in adult patients with diabetes or risk factors 1
• Adherence and percentage response to LDL-C-lowering medications should be assessed 4-12 weeks after initiation or dose adjustment 1
• Regular follow-up is essential to assess adherence, efficacy, and safety of both lifestyle and pharmacological interventions 2

Safety Considerations

• Statin therapy may increase the risk of myopathy and rhabdomyolysis, particularly in patients ≥65 years, with uncontrolled hypothyroidism, renal impairment, or on certain concomitant medications 4, 7
• Combination therapy with statins and fibrates or niacin increases the risk of myositis 1, 7
• In patients with a history of hemorrhagic stroke, statins should be used with caution 1