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 &

4. CAC scoring can reclassify patients at intermediate or borderline risk when a risk decision is uncertain.

CAC scoring is the last step of the three-step approach to enhance clinician-patient discussions in patients 40-75 years of age (Figure 2). Although this test is not routinely recommended, two high-quality prospective trials[9,10] showed that CAC scores can help in selected intermediate-risk patients for whom the risk decision is uncertain. A CAC score can help identify patients who are most likely to benefit from therapy or for whom statin therapy may be deferred (ie, CAC score of 0, indicating no, or a very low, burden of atherosclerosis).

Whereas other risk scores provide probabilities for ASCVD outcomes, the CAC score reveals the presence (or absence) and extent of atherosclerosis. It is important to also impress upon patients that there are some people in whom a CAC of zero does not guarantee a low-continued risk. These include those who have a 10-year risk ≥ 20%, are current cigarette smokers, have diabetes, or have a strong family history of premature CAD.

5. Screening for and management of FH should not be deferred until age 40 years and in secondary prevention patients; statins still benefit if age > 75 years.

The 2018 guideline emphasizes the value of identifying patients with familial hypercholesterolemia (FH) at any age (Figure 2). Once a patient with FH is identified, her or his relatives should be screened to identify those with a 1 in 2 risk for FH. Consistent with the 2013 guideline, the 2018 guideline does not recommend use of a risk estimator to determine statin eligibility as primary prevention for patients >75 years of age because more studies are needed to determine the benefit of treating this population. There is, however, evidence demonstrating the benefits of continuing statin therapy for secondary prevention of CVD. Indeed, the IMPROVE-IT trial demonstrated the benefits of intensively lowering LDL-C by adding ezetimibe in very high-risk patients > 75 years of age.[11]

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