The 2018 Guidelines on the Management of Blood Cholesterol

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How the medical community treats patients with high cholesterol changed dramatically in November 2013 when a new set of Guidelines for recommending cholesterol-lowering drugs was published. The newly published 2018 Guidelines both affirms that approach and adds several more specific recommendations.

A little history: the standard of care for those with high cholesterol before the 2013 Guidelines was for doctors to prescribe a statin—a prescription drug like Lipitor—to lower LDL (bad) cholesterol to a target figure. But the 2013 Guidelines abandoned that ‘treat-to-target’ approach. Instead, the new Guidelines recommended doctors take a more holistic approach based on assessing a patient’s overall 10-year heart disease risk.

As explained in my post, The NEW Guidelines For Cholesterol-Lowering Statin Meds, in broad strokes the 2013 guidelines state that if you are in one of the following four groups you have elevated heart disease risk and should take statins:

  1. those who already have cardiovascular disease
  2. anyone with LDL (bad) cholesterol of 190 mg/dL or higher
  3. anyone between 40 and 75 years of age who has Type 2 diabetes
  4. people between 40 and 75 who have an estimated 10-year risk of cardiovascular disease of 7.5 percent or higher.

Further, the 2013 debut of an online ASCVD Risk Calculator meant everyone could measure their 10-year risk. The fact that anyone could now calculate their own 10-year risk of heart disease if they had their own cholesterol lipid panel test results and a blood pressure reading was a big step forward in patients understanding their care and having informed discussions with their health care providers.

There was a lot of controversy in the medical community when these 2013 Guidelines and the Risk Calculator debuted. Many worried it would dramatically increase statin use while others thought the opposite. So it’s important that the recent update to these Guidelines continues with the holistic method of blood cholesterol treatment based on several factors rather than trying to lower cholesterol for all to a specific target figure.

While it still emphasizes lifestyle changes and a holistic approach for everyone, there is a key change in the 2018 Guidelines. For specific high-risk groups, there are new recommendations for statin treatment along with target figures for LDL (bad) cholesterol for these specific groups.

The 2018 Guideline on the Management of Blood Cholesterol, a full update of the 2013 Guidelines, was published in the AHA journal, Circulation, in November 2018. Quoted here are the Top 10 Take-Home Messages to Reduce Risk of Atherosclerotic Cardiovascular Disease Through Cholesterol Management:

  1. “In all individuals, emphasize a heart-healthy lifestyle.
  2. In patients with clinical ASCVD (meaning: anyone who already has cardiovascular disease), reduce low-density lipoprotein cholesterol (LDL-C) with high intensity statin therapy or maximally tolerated statin therapy.
  3. In very high-risk ASCVD, use a LDL-C threshold of 70 mg/dL (1.8 mmol/L) to consider addition of nonstatins to statin therapy.
  4. In patients with severe primary hypercholesterolemia (LDL-C level ≥190 mg/dL), without calculating 10-year ASCVD risk, begin high-intensity statin therapy without calculating 10- year ASCVD risk.
  5. In patients 40 to 75 years of age with diabetes mellitus and LDL-C ≥70 mg/dL, start moderate-intensity statin therapy without calculating 10-year ASCVD risk.
  6. In adults 40 to 75 years of age evaluated for primary ASCVD prevention, have a clinician–patient risk discussion before starting statin therapy.
  7. In adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dL, at a 10-year ASCVD risk of ≥7.5%, start a moderate-intensity statin if a discussion of treatment options favors statin therapy.
  8. In adults 40 to 75 years of age without diabetes mellitus and 10-year risk of 7.5% to 19.9% (intermediate risk), risk-enhancing factors favor initiation of statin therapy.
  9. In adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dL- 189 mg/dL, at a 10-year ASCVD risk of ≥7.5% to 19.9%, if a decision about statin therapy is uncertain, consider measuring CAC.
  10. Assess adherence and percentage response to LDL-C–lowering medications and lifestyle changes with repeat lipid measurement 4 to 12 weeks after statin initiation or dose adjustment, repeated every 3 to 12 months as needed.”

In a nutshell, the 2018 Guidelines continue to favor managing high cholesterol with Lo-Co lifestyle changes (food and exercise) rather than statin medication for all who do not fall into the 4 high risk segments. So if you do NOT have heart disease already, do NOT have diabetes, do NOT have LDL cholesterol of 190 or higher, and do NOT have a 10-year risk of heart disease of 7.5% or higher, you CAN manage your cholesterol and heart disease risk without medication.

Every adult has the ability to easily calculate their personal 10-year risk of cardiac disease. If you have your cholesterol test results and your blood pressure, you can use the calculator and understand your risk and whether you should consider (or not!) a statin medication. See my Resources page for more information and other online calculators.


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