New Cholesterol Guideline Recommends More Personalized Risk Assessment, Active Patient Involvement in Treatment Decisions

photo of Scott M. Grundy, M.D., Ph.D., FAHAScott M. Grundy, M.D., Ph.D., FAHA; Professor, UT Southwestern Medical Center and VA Medical Center, Dallas, Texas; Chair, 2018 Cholesterol Guideline writing committee

Shared decision-making to help health care providers and patients manage cholesterol across the lifespan is a focus of new guidelines that provide recommendations related to several patient conditions and scenarios.

The guideline authors, a panel of scientists and health experts from the American Heart Association and 11 other health organizations, made several recommendations based on analysis of numerous studies. The publication is an update to the 2013 guideline about management of cholesterol – a major risk factor for heart disease and stroke.

As a long-time researcher of cholesterol and lipoprotein metabolism, I fully support the latest guidelines. I believe they will help to save and improve more lives.

Here are the highlights:

The highest priority for treatment is given to patients who already have had a heart attack or stroke. These patients are treated first with statins with the aim of reducing their risk for subsequent cardiovascular event or death. Patients at very high risk for subsequent heart attack or stroke may benefit by the addition of newer cholesterol-lowering drugs to statin therapy.

  1. The guideline continues to emphasize a personalized, lifespan approach to the prevention, diagnosis and treatment of high cholesterol and the link to cardiovascular diseases. It emphasizes the understanding of lifetime risk for heart disease and stroke, and that high cholesterol at any age can increase risk. A healthy lifestyle remains a critical component to prevent and treat high cholesterol. Statins remain the cornerstone of treatment when medical interventions are necessary.
  2. The guideline recommends more personalized risk assessments. The well-known risk factors like smoking, high blood pressure, diabetes and high blood cholesterol are evaluated first. Next the guideline suggest looking at “risk enhancing factors,” such as family history and other medical conditions, that can provide a better perspective on a person’s risk. That’s important because a more detailed risk assessment can make a difference in what treatment a person needs.
  3. The guideline notes that, in some cases, a coronary artery calcium (CAC) test can help health care providers decide whether to start statin therapy when risk status may not be clear. A CAC score is calculated based on taking a CT scan of the heart and determining how much calcium plaque is building up in the heart’s arteries. The score helps to refine the assessment of risk for heart disease.
  4. The guideline recognizes the importance of identifying high LDL cholesterol in children, adolescents and young adults to address their risk before major health damage is done. It recommends earlier cardiovascular disease risk assessment and offers specific treatment recommendations based on overall lifetime risks at varying ages. In some cases, high cholesterol in children can identify a genetic issue and could trigger the need for testing throughout the extended family to find and treat others at increased risk.
  5. The guideline emphasizes personal, shared-decision-making discussions between patients and health care to ensure their individual risks, situations and preferences are fully addressed in any treatment. Ethnic background, age and a wide variety of personal health situations are among the factors reasonable for health care providers to consider when assessing risk.

The AHA has developed excellent companion materials to help stakeholders understand the guideline’s details.

Using data and metrics to manage cholesterol

There’s no ideal target for LDL cholesterol levels in the general population, but the guideline recognizes in principle that “lower is better.” U.S. population studies have suggested optimal total cholesterol levels are about 150 mg/dL, which corresponds to about 100 mg/dL for LDL cholesterol. Adults with cholesterol levels in this range tend to have lower rates of heart disease and stroke.

Major risk factors for CVD can be combined into an equation that can estimate chances for developing cardiovascular diseases over a certain time. The Check.Change.Control.Calculator helps people determine if they may be at risk for CVD and learn lifestyle changes to live healthier. The ASCVD Risk Calculator (see No. 2 above) allows health care providers to more closely assess a person’s specific risk level for CVD and determine the best course of lifestyle intervention or medication treatment.

When medication is needed, statins continue to provide the most effective lipid-lowering treatment in most cases. In a new data visualization, the Center for Health Metrics and Evaluation displays the proportion of U.S. adults who are eligible for statins with the proportion eligible that are actually taking statins, based on the cholesterol guidelines statin eligibility groups. Data are stratified by gender and race/ethnicity where available.

Managing LDL cholesterol effectively through lifestyle changes or appropriate medication is critical to reducing lifetime risk of cardiovascular disease. These guidelines are yet another example of the American Heart Association’s crucial mission: to be a relentless force for a world of longer, healthier lives.