Cholesterol Guidelines Emphasize Healthy Lifestyle, Personalization, and Stepped Treatment

Ivor Benjamin, MD, FAHA

The American Heart Association and the American College of Cardiology have released new clinical practice guidelines on the management of blood cholesterol.

The guidelines emphasized the importance of a healthy lifestyle for reducing atherosclerotic cardiovascular disease (ASCVD) risk, an evaluation individual risk factors in estimating 10-year CVD risk, and a stepped approach to escalating statin therapy, adding ezetimibe if lipid levels remain high, and finally to introducing a PCSK9 inhibitor if further reduction is required.

The 2018 guidelines were presented at the AHA Scientific Sessions 2018 in Chicago, Il.

“The updated guidelines reinforce the importance of healthy living, lifestyle modification, and prevention. They build on the major shift we made in our 2013 cholesterol recommendations to focus on identifying and addressing lifetime risks for cardiovascular disease,” said Ivor Benjamin, MD, FAHA, president of the American Heart Association, in a statement.

The guidelines also stressed the importance of a personalized care plan tailored to each patient’s history and risk factors. The guidelines include an update to the risk calculator introduced in the 2013 guidelines that adds “risk-enhancing factors” such as family history and ethnicity, as well as conditions including metabolic syndrome, chronic kidney disease, chronic inflammatory conditions, premature menopause or pre-eclampsia, and high lipid biomarkers.

“High cholesterol treatment is not one size fits all, and this guideline strongly establishes the importance of personalized care,” said Michael Valentine, MD, FACC, president of the American College of Cardiology, in a statement.

A supplement to the guidelines, focused on risk-assessment tools, gives providers a more detailed guide to the use of quantitative tools for estimating 10-year cardiovascular disease risk. The authors note that the pooled cohort equations may underestimate CVD risk in patients from certain racial/ethnic groups, those with lower socioeconomic status, or those with chronic inflammatory diseases, while overestimating risk in patients with high socioeconomic status or who have benefitted from careful preventive health care measures.

When lifestyle modifications aren’t sufficient to manage cholesterol levels, the guidelines recommend a stepped approach that begins with statins before progressing to ezetimibe in addition to statins, and finally to the addition of a PCSK9 inhibitor.

The top-level recommendations state that for certain patients at high risk or who do not respond sufficiently to statins or ezetimibe in addition to statins, “adding a PCSK9 inhibitor is reasonable, although the long-term safety (>3 years) is uncertain and cost effectiveness is low at mid-2018 list prices.”

“There have been concerns over the cost of PCSK9 inhibitors and some insurance companies have been slow to cover them, so it’s important to note that the economic value of these new medications may be substantial only for a very specific group of people for whom other treatments haven’t worked,” Benjamin said.

The guidelines were published simultaneously in the American Heart Association journal, Circulation, and the Journal of the American College of Cardiology. The supplement, “Use of Risk Assessment Tools to Guide Decision-Making in the Primary Prevention of Atherosclerotic Cardiovascular Disease,” was also published in those journals.