Highlights
of the 2018 Guideline on the
Management of Blood Cholesterol
Importance of Cholesterol Management
The “2018 Guideline on the Management of Blood Cholesterol” is an
update to the 2013 guideline on diagnosing, treating, and monitoring
high cholesterol.
Fifty-six million (48.6%) US adults over 40 years of age are eligible
for statin therapy on the basis of the 2013 guideline for managing
blood cholesterol from the American College of Cardiology and the
American Heart Association. This is signicant when you consider that
having a high level of low-density lipoprotein cholesterol (LDL-C) is a
major risk factor for atherosclerotic cardiovascular disease (ASCVD).
Because LDL-C contributes to fatty buildups and narrowing of the
arteries (atherosclerosis), it’s often called the “bad” cholesterol, and
in fact, high LDL-C at any age can cumulatively increase the risk for
heart disease and stroke.
While there is no ideal target blood level for LDL-C, the 2018
guideline recognizes, in principle, that “lower is better.” Studies
suggest that an optimal total cholesterol level is about 150 mg/dL,
with LDL-C at or below 100 mg/dL, and adults with LDL-C in this level
have lower rates of heart disease and stroke.
Risk Assessment
The 2018 guideline recommends that healthcare providers conduct
a detailed risk assessment with their patients through an ASCVD risk
calculator (static.heart.org/riskcalc/app/index.html#!/baseline-risk),
which providers can use to discuss risks and treatment options with
patients. A consumer-facing risk calculator is available as well at
www.heart.org/ccccalculator. This calculator combines all major risk
factors to estimate a patient’s probability for developing ASCVD. Risk
factors include smoking, high blood pressure, abnormal cholester-
ol, and diabetes. Because atherosclerosis progresses over a lifetime,
age counts as a risk factor, too. When the ASCVD risk status is uncer-
tain, a coronary artery calcium test may clarify risk for patients ages
40 to 75, and it may also help decide whether to start or restart statin
therapy.
Along with traditional cardiovascular disease risk factors like
smoking, high blood pressure, high cholesterol, and high blood
sugar, the guideline now calls for further review in some people ages
40 to 75 of risk-enhancing factors such as family history and other
health conditions. The presence or absence of risk-enhancing factors
in this age group without diabetes and 10-year risk of 7.5% to 19.9%
can help further determine whether patients should start or intensify
statin therapy.
Patients with extremely high LDL-C (190 mg/dL or more) or other
conditions that can increase their ASCVD risk, and those who have
been diagnosed with cardiovascular disease, need immediate
intervention with high-intensity statins to manage their cholesterol
without further risk assessment.
The 2018 guideline also recognizes the importance of identifying
and managing high LDL-C in children, adolescents, and young
adults to reduce their lifetime exposure to the health effects of high
cholesterol. Most children can reduce their lifetime ASCVD risk by
practicing healthier lifestyles. In some cases, high cholesterol in
children can point to a genetic issue like familial hypercholesteremia,
prompting screening of family members to identify those who are at
increased risk.
Primary Prevention
The 2018 guideline recommends that for adults 20 years or older who
are free from ASCVD (and not on lipid-lowering therapy), measure
LDL-C with either a fasting or nonfasting plasma lipid prole when esti-
mating ASCVD risk, and document baseline LDL-C. For adults 20 years
or older who have an initial nonfasting lipid prole with triglycerides
400 mg/dL or higher, repeat the lipid prole with the patient fasting to
establish fasting triglyceride levels and baseline LDL-C.
As with children, most patients can reduce their lifetime ASCVD
risk through healthier lifestyle practices. Encourage patients to
reduce their caloric intake of saturated fat and dietary cholesterol
and to eliminate trans fat completely. In addition to these dietary
changes, patients should strive for an average of 40 minutes of
moderate to vigorous physical activity 3 to 4 times per week. But
even moderate amounts of activity can reduce risk for patients who
achieve this goal, and patients with metabolic syndrome may also
benet from physical activity.
When lifestyle interventions alone are not enough to lower LDL-C,
statins generally provide the most effective lipid-lowering treatment.
There are 3 main treatment regimens for statins:
• High intensity, which typically lowers LDL-C by 50% or more
• Moderate intensity, which lowers LDL-C by 30% to 49%
• Low intensity, which lowers LDL-C by 30% or less
Use a stepwise approach to manage high cholesterol, adding
therapies as tolerated until the cholesterol levels are lowered
adequately. If a patient has problems taking a statin or if a statin
alone doesn’t sufciently lower LDL-C additional drug options are
available. Adding a bile acid sequestrant or ezetimibe to a statin
regimen further lowers LDL-C by approximately 15% to 30% and 13%
to 20%, respectively. And adding a PCSK9 inhibitor to a statin regimen
has been shown to further reduce LDL-C by 43% to 64%.
Patients with extremely high LDL-C (190 mg/dL or higher) have a
high lifetime risk for a cardiovascular event. For patients ages 20 to
75, providers should prescribe a maximally tolerated statin.
Adults ages 40 to 75 who have diabetes are usually considered
at moderate to high risk for cardiovascular disease. The guideline
recommends moderate-intensity statins, regardless of the patient’s
estimated 10-year risk for ASCVD (Figure 1).
Secondary Prevention
For patients who have had a serious cardiovascular incident or pro-
cedure, secondary prevention may reduce the risk of another event.
Providers should use an ideal LDL-C threshold of less than 70 mg/dL
when considering adding ezetimibe and PCSK9 inhibitors to an exist-
ing statin therapy (Figure 2).
Figure 1. Primary Prevention.
apoB indicates apolipoprotein B; ASCVD, atherosclerotic cardiovascular disease; CAC, coronary artery calcium; hsCRP,
high-sensitivity C-reactive protein; LDL-C, low-density lipoprotein cholesterol; and Lp(a), lipoprotein (a).
Figure 2. Secondary prevention.
ACS indicates acute coronary syndrome; ASCVD, atherosclerotic cardiovascular disease; HDL-C, high-density lipoprotein cholesterol;
LDL-C, low-density lipoprotein cholesterol; MI, myocardial infarction; and PCSK9i, PCSK9 inhibitor. *Very high risk includes a history of
multiple major ASCVD events or 1 major ASCVD event and multiple high-risk conditions.
Monitoring
Once patients begin a treatment plan, providers
should reassess at 4 to 12 weeks with a fasting or
nonfasting lipid test and check for statin intoler-
ance, and retest every 3 to 12 months if needed.
Using the percentage reduction in LDL-C (rather
than total cholesterol) in follow-up monitoring of
patients can help you estimate how well the statin
medication is working.
Lowering LDL-C levels by 1% generally equals
about 1% reduction in heart disease and stroke
risk, but the effect can be even greater when
starting with higher baseline levels of LDL-C. On
the basis of several large studies, it's estimated
that reducing LDL-C levels with statins by about
38.7 mg/dL can reduce heart disease and stroke
risk by about 21%, based on the results of several
large studies.
Implementing the 2018
Guideline Recommendations
When initiating treatment plans and before pre-
scribing therapy, providers should
• Allow patients to ask questions and express
concerns and preferences about their ability
and likelihood to follow and stick to the
lifestyle and medication plan
• Emphasize the potential for lowering the
patient’s cardiovascular disease risk
• Discuss any possible drug interactions and
adverse effects
• Address issues that factor into, or may
become a barrier to, a shared-decision plan,
such as costs and the patient’s overall health
The 2018 guideline recommends offering
options such as phone and calendar reminders,
educational activities, and simplied medication
doses to help patients stick to their treatment
plans. The 2018 guideline also includes
considerations for special populations in the
United States:
• Racial/ethnic groups (Section 4.5.1)
• Women (Section 4.5.3)
• People with diabetes (Section 4.3)
• People with chronic kidney disease
(Section 4.5.4)
• People with chronic inammatory
conditions/HIV (Section 4.5.5)
• Older adults (Section 4.4.4.1)
• People with hypertriglyceridemia
(Section 4.5.2)
To download the full version of the 2018 Cholesterol Guideline, please visit
https://professional.heart.org/professional/ScienceNews/UCM_502791_2018-Cholesterol-Management-Guideline.jsp,
or download a QR code reader app and scan this QR code with your smartphone.
© Copyright 2018 American Heart Association, Inc., a 501(c)(3) not-for-prot. All rights reserved.
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