2018 AHA/ACC Multisociety Cholesterol Guideline vs 2019 ESC/EAS Dyslipidemia Guidelines: 5 Things to Know

Andi Shahu, MD, MHS; David I. Feldman, MD, MPH; Erin D. Michos, MD, MHS, FACC, FAHA, FASE


June 30, 2021

Editorial Collaboration

Medscape &

The 2018 American Heart Association (AHA)/American College of Cardiology (ACC) Multisociety Cholesterol Guideline and the 2019 European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) Guidelines for the Management of Dyslipidaemias provide the most current recommendations for the management of blood cholesterol and prevention of atherosclerotic cardiovascular disease (ASCVD). Here are five notable similarities and differences between the AHA/ACC and ESC/EAS guidelines.

1. There are many commonalities between the AHA/ACC and ESC/EAS guideline recommendations regarding prevention of ASCVD.

Both the AHA/ACC and ESC/EAS guidelines recommend estimating the patient's 10-year ASCVD risk as part of the initial assessment in primary prevention. Whereas the ESC/EAS guidelines endorse the European Systematic Coronary Risk Evaluation (SCORE), a country-specific tool to estimate the 10-year risk for fatal ASCVD events, the AHA/ACC guideline endorses the Pooled Cohort Equations to estimate 10-year risk for nonfatal and fatal ASCVD events.

Each of these assessment tools has limitations in predicting 10-year risk for ASCVD. For example, because SCORE and the Pooled Cohort Equations are derived from data drawn from old cohorts, these tools may overestimate or underestimate risk in different subpopulations, particularly groups that may be underrepresented in the original cohorts (eg, persons of non-White Hispanic or Black race/ethnicity or people of lower socioeconomic status). To overcome these limitations, both guidelines recommend that clinicians consider ASCVD "risk enhancers" (AHA/ACC guideline) or "risk modifiers" (ESC/EAS guidelines) when treatment decisions are uncertain and as part of the shared decision-making process between clinicians and patients. Both include such factors as family history of premature ASCVD and comorbidities (eg, inflammatory conditions and chronic kidney disease). Whereas the ESC/EAS guidelines consider psychosocial factors, such as social deprivation and major psychiatric disorders, the ACC/AHA guideline considers sex-specific factors (eg, patients with preeclampsia, premature menopause); race/ethnicity factors (eg, patients of South Asian ancestry); and elevated levels of biomarkers such as C-reactive protein and lipoprotein (a) [Lp(a)].

In cases where the need for statin therapy is still uncertain, the AHA/ACC guideline states that coronary artery calcium (CAC) assessment is a reasonable tool (IIa recommendation) to refine a patient's ASCVD risk estimation. The CAC score is also recommended to help guide shared decision-making between clinicians and patients. In contrast, the ESC/EAS guidelines consider assessment of arterial (carotid or femoral) plaque (IIa) and CAC assessment (IIb) as risk modifiers for low- or moderate-risk individuals.

The AHA/ACC and ESC/EAS guidelines stress the importance of lifestyle modifications and shared decision-making regarding risks and benefits of interventions for ASCVD risk reduction. In both guidelines, statin therapy is considered the first-line pharmacologic treatment in secondary prevention and is also recommended in primary prevention for patients with diabetes, those with heterozygous familial hypercholesterolemia, and those determined to be at elevated risk for ASCVD.


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