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2018 ACC/AHA Multisociety Guideline on the Management of Blood Cholesterol

Written by John Steuter, MD

The 2018 American College of Cardiology (ACC) and American Heart Association (AHA) multisociety guidelines aim at reducing risk of atherosclerotic cardiovascular disease (ASCVD) through lipid management. Compared to the 2013 these guidelines emphasize a more intensive approach based on recent controlled studies and expert consensus.

Below are the top 10 takeaways from the 2018 ACC/AHA Guidelines:

1. In all individuals, emphasize a heart-healthy lifestyle. 

A healthy lifestyle reduces ASCVD risk at all ages.

  • Children and teens: A healthy lifestyle can reduce development of risk factors and is the foundation of ASCVD risk reduction.
  • Adults 20 to 39 years of age: An assessment of lifetime risk facilitates the clinician–patient risk discussion and emphasizes intensive lifestyle efforts.
  • All age groups: Lifestyle therapy is the primary intervention for metabolic syndrome. 

2.  In patients with clinical ASCVD, reduce low-density lipoprotein cholesterol (LDL-C) with high-intensity statins or maximally tolerated statins to decrease ASCVD risk. 

Greater LDL-C reductions on statin therapy, leading to lower LDL-C levels, lower significant risk. Use a maximally tolerated statin to reduce LDL-C levels by ≥50%. 

3.  In very high-risk ASCVD, use an LDL-C threshold of 70 mg/dl (1.8 mmol/L) to consider addition of nonstatins to statins. 

  • High-risk ASCVD patients: It is reasonable to add ezetimibe to maximally tolerated statin therapy when the LDL-C level remains ≥70 mg/dl (≥1.8 mmol/L).
  • Very high risk ASCVD patients: LDL-C level remains ≥70 mg/dl on maximally tolerated statin and ezetimibe therapy, adding a PCSK9 inhibitor is reasonable, although the long-term safety (>3 years) is uncertain and cost-effectiveness is low at mid-2018 prices. 

4.  In patients with severe primary hypercholesterolemia (LDL-C level ≥190 mg/dl [≥4.9 mmol/L]) without calculating 10-year ASCVD risk, begin high-intensity statin therapy. 

If the LDL-C level remains ≥100 mg/dl, adding ezetimibe is reasonable. If the LDL-C level on statin plus ezetimibe remains ≥100 mg/dl and the patient has multiple factors that increase subsequent risk of ASCVD events, a PCSK9 inhibitor may be considered, although the long-term safety (>3 years) is uncertain and economic value is uncertain at mid-2018 prices. 

5.  In patients 40 to 75 years of age with diabetes mellitus and an LDL-C level of ≥70 mg/dl, start moderate-intensity statins without calculating 10-year ASCVD risk.

In patients with diabetes mellitus at higher risk, especially those with multiple risk factors or those 50 to 75 years of age, it is reasonable to use a high-intensity statin to reduce the LDL-C level by ≥50%.

6.  In adults 40 to 75 years of age evaluated for primary ASCVD prevention, have a clinician–patient risk discussion before starting statin therapy. 

Risk discussion should include a review of major risk factors (e.g., cigarette smoking, elevated blood pressure, LDL-C, hemoglobin A1c [if indicated], and calculated 10-year risk of ASCVD); the presence of risk-enhancing factors (see #8); the potential benefits of lifestyle and statin therapies; the potential for adverse effects and drug–drug interactions; consideration of costs of statin therapy; and patient preferences and values in shared decision-making. 

7.  In adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dl (≥1.8 mmol/L), at a 10-year ASCVD risk of ≥7.5%, start a moderate-intensity statin if a discussion of treatment options favors statin therapy. 

Risk-enhancing factors favor statin therapy (see #8). If risk status is uncertain, consider using CAC to improve specificity (see #9). If statins are indicated, reduce LDL-C levels by ≥30%, and if 10-year risk is ≥20%, reduce LDL-C levels by ≥50%. 

8.  In adults 40 to 75 years of age without diabetes mellitus and 10-year risk of 5%-19.9%, risk-enhancing factors favor initiation of statin therapy. 

Risk-enhancing factors include family history of premature ASCVD; persistently elevated LDL-C levels ≥160 mg/dl (≥4.1 mmol/L); metabolic syndrome; chronic kidney disease; history of preeclampsia or premature menopause (age <40 years); chronic inflammatory disorders (e.g., rheumatoid arthritis, psoriasis, or chronic HIV); high-risk ethnic groups (e.g., South Asian); persistent elevations of triglycerides ≥175 mg/dl (≥1.97 mmol/L); and, if measured in selected individuals, apolipoprotein B ≥130 mg/dl or ≥2500 nmol/L, high-sensitivity C-reactive protein ≥2.0 mg/L (190 nmol/L), ABI <0.9, and lipoprotein (a) ≥50 mg/dl or 125 nmol/L, especially at higher values of lipoprotein (a). 

9.  In adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dl-89 mg/dl (≥1.8-4.9 mmol/L), at a 10-year ASCVD risk of ≥7.5%-19.9%, if a decision about statin therapy is uncertain, consider measuring CAC. 

If the CAC score is zero, treatment with statin therapy may be withheld or delayed, except in cigarette smokers, those with diabetes mellitus, and those with a strong family history of premature ASCVD. A CAC score of 1-99 favors statin therapy, especially in those >55 years of age. For any patient, if the CAC score is ≥100 Agatston units or ≥75th percentile, statin therapy is indicated unless otherwise deferred by the outcome of clinician–patient risk discussion. 

10.  Assess adherence and percentage response to LDL-C–lowering medications and lifestyle changes with repeat lipid measurement four to 12 weeks after statin initiation or dose adjustment, repeated every three to 12 months as needed. 

Define responses to lifestyle and statin therapy by percentage reductions in LDL-C levels compared with baseline. In ASCVD patients at very high-risk, triggers for adding nonstatin drugs are defined by threshold LDL-C levels ≥70 mg/dl (≥1.8 mmol/L) on maximal statin therapy.

At Bryan Heart we are proud to offer expert lipid management including at dedicated lipid clinic. If you have questions about the 2018 ACC/AHA Multisociety Guideline on the Management of Blood Cholesterol or would like to refer a patient, call 402-483-3333.


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