2018 Updated AHA/ACC Multisociety Cholesterol Guideline: 5 Things to Know

Neil J. Stone, MD, FACC; Scott M. Grundy MD, PhD


November 01, 2019

Editorial Collaboration

Medscape &

2. Nonstatin adjunctive therapy benefits very high-risk patients.

Because patients at the highest absolute baseline risk will benefit most from aggressive therapy to lower LDL-C, the 2018 update identified a "very high-risk" group among secondary prevention patients (Figure 1). If maximally tolerated statin therapy and lifestyle modifications fail to lower LDL-C to <70 mg/dL in these very-high risk patients, clinicians may consider a nonstatin as adjunctive therapy. Ezetimibe is recommended first-line because it is easily available and affordable (generics are available) and has longer safety data.[4] If LDL-C remains ≥ 70 mg/dL, treatment with a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor (alirocumab or evolocumab) should then be considered.[5,6] The 2018 guideline continues to emphasize percent of LDL-C lowering to determine efficacy and adherence.

The 2018 guideline also recommend an LDL-C threshold of 100 mg/dL for selected high-risk individuals among those with heterozygous familial hypercholesterolemia,[1] owing to their lifelong exposure to severe elevations of LDL-C.[7] These patients too should benefit from nonstatin adjunctive therapy if statin monotherapy fails to achieve an LDL-C level <100 mg/dL.

3. Clinician-patient risk discussions before deciding on treatment are essential.

The 2018 guideline reemphasizes the importance of clinician-patient risk discussions across all age groups, stressing that treatment decisions should be based on a full consideration of multiple factors affecting individual patient's risk, combined with the patient's motivation for initiation of treatment. For patients aged 40-75 years, in whom there are the most RCT data, the guideline offers a three-step approach (Figure 2) to help them understand their risk.

Step 1: Calculate the patient's 10-year risk. Clinicians may use nonfasting lipid measurements for this calculation. The pooled cohort equations (PCE) include major risk factors that are easily available at a clinic or office visit. Although there were initial concerns that PCE event rates were overpredicted in women, a follow-up analysis of data from the Women's Health Initiative resolved this issue.[8] The 2013 recommendation was for clinician-patient risk discussions before statin therapy for patients with a 10-year ASCVD risk ≥7.5%. The 2018 update further divides patients aged 40-75 years into low (< 5%), borderline (5%-<7.5%), intermediate (7.5%-19.9%), and high (≥ 20%) risk subgroups. Risk discussion is pivotal for patients in the borderline- and intermediate-risk groups.

Step 2: Determine enhancing factors. Enhancing factors further personalize the clinician-patient risk discussion. The 2018 guideline provides a more comprehensive list of enhancing factors (Figure 2). Presence of enhancing factors favors the use of a statin in the borderline- and intermediate-risk groups.

Although standardized risk assessment algorithms are not available for other age groups, clinician-patient discussions are still of utmost importance. Treatment decisions for these patients should be determined on the basis of patterns of risk factors and rough estimates of lifetime risk. In all groups, lifestyle intervention is paramount, and risk discussions must be used to motivate patients to adopt a healthy lifestyle.

Step 3: Determine the coronary artery calcium (CAC) score. This is discussed in more depth in the next section.


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