2018 cholesterol guidelines restore thresholds, address additional treatment groups

November 21, 2018   /

By Will Boggs MD

NEW YORK (Reuters Health) - The new 2018 joint guidelines on the management of blood cholesterol include some treatment thresholds that had been abandoned, expand recommendations regarding nonstatin treatments and add guidelines for children and young adults, as well as ethnic groups not included in earlier editions.

"LDL cholesterol should be measured in all adults, and its management should be done according to the guidelines," said Dr. Scott M. Grundy of the University of Texas Southwestern Medical Center, in Dallas, who chaired the writing committee.

"LDL cholesterol should be measured in children and adolescents whose parents have high cholesterol or premature coronary heart disease or stroke," he told Reuters Health by email.

Dr. Grundy and colleagues from the American Heart Association, the American College of Cardiology and other national associations undertook an extensive evidence review to update guidelines for the practical management of patients with high blood cholesterol and related disorders.

Their report was published online November 10 in Circulation to coincide with a presentation at the American Heart Association meeting in Chicago.

For all individuals, the guidelines emphasize the importance of a heart-healthy lifestyle throughout life and encourage clinician-patient discussions of risk before starting statin therapy.

The new guidelines reflect a partial return to LDL-cholesterol thresholds for treatment. For example, for patients with LDL-cholesterol levels of 190 mg/dL (4.9 mmol/L) or higher, high-intensity statin therapy is recommended regardless of atherosclerotic cardiovascular disease (ASCVD) risk.

Similarly, patients with diabetes whose LDL-cholesterol is 70 mg/dL (1.8 mmol/L) or higher should start moderate-intensity statin therapy regardless of their 10-year ASCVD risk, according to the new advice.

For patients without diabetes but with LDL-cholesterol levels of 70 mg/dL or higher, the appropriate treatment should take into account their 10-year risk of ASCVD, the authors say.

Coronary-artery calcium (CAC) can also be used to support treatment decisions, and it is reasonable to withhold statins and reassess patients with a CAC of zero, the team adds.

Nonstatin therapy should be considered in very-high-risk patients where LDL-cholesterol levels below 70 mg/dL cannot be achieved with statins alone. Ezetimibe is the first choice, based mainly on economic considerations, while PCSK9 inhibitors should be reserved for patients with LDL-cholesterol levels that remain elevated on maximally tolerated statin and ezetimibe therapy.

The 2018 guidelines add recommendations for children and adolescents with lipid disorders, especially those with obesity or other metabolic risk factors.

The previous guideline addressed the increased ASCVD risk in blacks. The new guideline also highlights higher ASCVD risk in South Asians, the potential for overestimation of risk for East Asians, and the heterogeneity of risk among Hispanics.

Finally, the guidelines recommend assessment of adherence and percentage response to LDL-cholesterol-lowering medications and lifestyle changes with repeat lipid measurement four to 12 weeks after statin initiation or dose adjustment, repeated every three to 12 months as needed, with the goal of maintaining LDL-cholesterol levels below 70 mg/dL.

"Ultimately, the value of a guideline is determined by how effectively it is implemented into practice and by how much morbidity and mortality are avoided through its application," writes Dr.