High serum cholesterol is a major risk factor for cardiovascular disease (CVD), the leading cause of death among men and women in the United States. One in 5 of youths aged 6 to 19 years has at least 1 abnormal cholesterol measure,1 and almost half of US adults older than 40 years are eligible for statin therapy for the management of high cholesterol.2 In addition, familial hypercholesterolemia affects up to 1 in 200 individuals; with elevated total cholesterol and low-density lipoprotein cholesterol (LDL-C), these individuals have a 20-fold increased risk of CVD.3 Given the high prevalence and broad impact on the population, a life course approach to screening, detection, and management of cholesterol is necessary to minimize atherosclerotic CVD (ASCVD) risk and premature morbidity and mortality.
The American College of Cardiology and American Heart Association in partnership with multiple other professional societies, including the Preventive Cardiovascular Nurses Association, released a new guideline in November 2018 for cholesterol management in children, adolescents, and adults.4 This guideline reflects new evidence generated since the last focused guideline was published in 2013. Key changes in the new guideline include refinement of risk assessment with the addition of other risk-enhancing factors and coronary artery calcium (CAC) score as well as selective use of nonstatin therapies as treatment adjuncts in secondary prevention.
The new guideline emphasizes reducing lifetime ASCVD risk through a heart-healthy lifestyle across the life course. It is recommended to review lifestyle habits (eg, diet, physical activity, weight or body mass index, and tobacco use), endorse a healthy lifestyle, and provide relevant advice, materials, or referrals.
Shared decision making is central to the guideline with clinician-patient risk discussion guided by assessment of ASCVD risk using the ASCVD Risk Estimator,5 potential for ASCVD risk-reduction benefit, adverse effects, drug-drug interactions, and patient preferences. The new guideline establishes the following 10-year ASCVD risk categories: low risk (<5%), borderline risk (5% to <7.5%), intermediate risk (7.5% to <20%), and high risk (≥20%). For young adults who are at a low 10-year risk, communication of lifetime ASCVD risk may be helpful in promoting adherence to healthy lifestyle recommendations.
New in this guideline, in addition to assessment of ASCVD risk, consideration of other risk-enhancing factors is recommended to guide tailoring of treatment decisions especially among individuals in the intermediate-risk group. The risk-enhancing factors, listed in Table 1, may or may not independently predict risk in the general population, but they can be useful in the clinician-patient risk discussion as specific factors that influence risk. The presence of these atherogenic factors in an individual may help to confirm a higher risk state and thereby support a decision to initiate or intensify statin therapy. Furthermore, when risk status is uncertain in adults older than 40 years, a CAC score is an emerging risk estimation tool to facilitate shared decision making. Coronary artery calcium measurement may provide a more precise understanding of risk and benefit of treatment, particularly for those at an intermediate risk, and select individuals at a borderline risk, who may be reluctant to initiate or reinstitute statin therapy. If the CAC score is zero in these individuals and there are no higher risk conditions, statin therapy can be deferred, whereas a CAC score of 100 or greater favors statin initiation.
Consistent with the 2013 guideline, statins remain the first-line lipid-lowering agents for ASCVD risk reduction. The new guideline is consistent in recommending moderate- or high-intensity statin therapy for the following groups: (1) clinical ASCVD, (2) diabetes mellitus with LDL-C of 70 mg/dL or greater, (3) 40 to 75 years old with LDL-C of 70 to 189 mg/dL and 10-year ASCVD risk of 7.5% or greater, and (4) severe hypercholesterolemia (LDL-C ≥ 190 mg/dL). Although magnitude of reduction will vary by individual, high-intensity statin therapy typically lowers LDL-C levels by 50% or greater and moderate-intensity therapy by 30% to 49%. For secondary prevention, the guideline introduces a threshold of LDL-C of 70 mg/dL or greater for consideration of newer, nonstatin cholesterol-lowering agents, including ezetimibe and PCSK9 inhibitors. Nonstatin cholesterol-lowering agents will be mainly limited to secondary prevention in individuals at a very high risk of new ASCVD events and those who have had limited response or intolerance to statins.
Use of patient education materials and decision support tools to promote understanding of ASCVD risk as well as potential risk reduction from lipid-lowering therapy can aid in the clinician-patient risk discussion. Table 2 provides a variety of resources to support cholesterol management efforts, including risk discussion. Discussion of potential out-of-pocket cost of therapy to the patient is essential because of the direct influence on an individual's ability to adhere to the agreed-upon treatment plan. A teach-back approach where an individual is encouraged to verbalize what was heard (eg, personal ASCVD risk, available options, and risks/benefits) allows a clinician to address any misunderstanding.
The new 2018 cholesterol guideline reflects the rapidly evolving science supporting ASCVD risk estimation and cholesterol management strategies across the life course. Implementation of the guideline to achieve reductions in CVD morbidity and mortality will require effective clinician-patient discussion and shared decision making.
1. Nguyen D, Kit B, Carroll M. Abnormal cholesterol among children and adolescents in the United States, 2011–2014. NCHS Data Brief
2. Pencina MJ, Navar-Boggan AM, D'Agostino RB Sr., et al. Application of new cholesterol guidelines to a population-based sample. N Engl J Med
3. Goldberg AC, Hopkins PN, Toth PP, et al. Familial hypercholesterolemia: screening, diagnosis and management of pediatric and adult patients: clinical guidance from the National Lipid Association Expert Panel on Familial Hypercholesterolemia. J Clin Lipidol
4. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. J Am Coll Cardiol