Updated Cholesterol Guidelines Emphasize Personalization

Considering individualized risk factors may help doctors target treatment more accurately.

Medically reviewed in November 2020

One in three adults in the United States deal with high blood cholesterol. Lowering it is important because high cholesterol is a major risk factor for heart disease. The good news: clinicians have a new set of guidelines to help them manage it.

And this time, it’s personal.

"High cholesterol treatment is not one size fits all, and this guideline strongly establishes the importance of personalized care," said C. Michael Valentine, MD, president of the American College of Cardiology (ACC), in a statement. The ACC, along with the American Heart Association and 10 other health organizations, released the recommendations in November 2018.

Taking a more personalized approach
In the past, treatment for high cholesterol tended to be prescribed mostly on the basis of a patient’s cholesterol numbers as derived from a blood test. Now, doctors are advised to look at a patient’s overall heart health and heart risk within a broader context when thinking about therapy options.

Personalizing care in this way involves building on some of the traditional heart disease risk factors that clinicians consider—such as smoking, age and high blood pressure—to better understand a patient’s overall risk for heart disease and to help decide on a course of treatment.

Doctors are now advised to contemplate additional “risk-enhancing factors” such as:

  • family history of early heart disease
  • ethnicity
  • conditions such as kidney disease or inflammatory diseases (such as psoriasis or rheumatoid arthritis)
  • history of premature menopause or preeclampsia

After considering a patient’s risk factors and projected risk of heart disease, if the patient and physician are still on the fence about whether to begin addressing cholesterol levels through lifestyle changes or cholesterol-lowering drugs, the new guidelines recommend one more step: coronary artery calcium (CAC) scores.

What does calcium have to do with heart health?
Most folks know calcium as an important nutrient needed to build strong bones, but it also helps keep our muscles contracting, our hearts beating and our nerves signaling.

When there’s a buildup of plaque in the arteries, calcium may also accumulate. Using a computed tomography (CT) scan, doctors can measure the amount of calcium in the arteries that supply blood to the heart to help estimate the chances that those arteries may someday become blocked, which could lead to a heart attack or stroke. 

Patients at low or high risk for narrowed and clogged arteries (a condition called atherosclerotic cardiovascular disease, or ASCVD) probably don’t need their CAC measured because their choices will be obvious: Low-risk patients will likely be advised to make lifestyle changes to address cholesterol levels, while high-risk patients will probably need to start taking a cholesterol-lowering drug.

But for those who fall into a grey area of risk, the CAC score can help with choosing whether to start medication or not.

How risk translates into treatment
The new guidelines help translate a patient’s overall risk—based on factors such as age, cholesterol levels, other health conditions and ASCVD risk—into a plan for treatment. Some examples:

  • People with levels of low-density lipoprotein (LDL)—the “bad” cholesterol—of 190 mg/dL (milligrams per deciliter of blood) or more would begin high-intensity cholesterol-lowering drugs called statins immediately, without any further assessment needed.
  • Those with diabetes who are 40 to 75 years old can start a statin without any other risk assessment.
  • Adults without diabetes and with LDL values of 70 to 189 mg/dL would undergo an assessment for their ASCVD risk over the next 10 years. That score would be considered along with risk-enhancing factors to determine if lifestyle changes such as diet tweaks or exercise are all they need, or if a statin would be a good idea, too. An ASCVD risk score of less than 5 percent means low risk in the next 10 years, whereas a score of 20 percent or more indicates high risk—and the need for a statin. An estimation of ASCVD risk considers factors like smoking, other cholesterol values, blood pressure and age.

What else makes the new guidelines different?
The risk-enhancing factors put the “person” in the personalized approach to these cholesterol treatment guidelines. A clinician can talk with patients about how factors such as family history, ethnicity and a personal history of certain diseases affect their risk. Where the evidence is still mixed, the CAC score can help break the statin-or-not stalemate.

The guidelines—which update recommendations published in 2013—also recommend the use of other, newer cholesterol-lowering drugs for people with very high risk for ASCVD if statins don’t do the trick. Ezetimibe, which blocks the absorption of cholesterol in the intestine, is typically prescribed to be used in combination with a statin. PCSK9 inhibitors are also on the treatment menu. These drugs target and disable a liver protein that allows excess LDL to stay in the blood.

Another novel twist: Because some cholesterol-lowering medications—particularly PCSK9 inhibitors—can be pricey, the recommendations emphasize taking cost into consideration when deciding on their use.

The guidelines also call for an early start to cholesterol testing. In keeping with American Academy of Pediatrics recommendations, they suggest screening in children age 9 to 11 years and then a follow-up when they become young adults, at ages 17 to 21. For children with a strong family history of heart disease or inherited high cholesterol, this screening could reasonably be done when they are as young as 2 years old.

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