Reports from recent years have shown that nearly 80 million US adults either have low-density lipoprotein cholesterol (LDL-C) levels that fall in the range where pharmacological management is recommended or have other health conditions that place them at high risk for heart disease and stroke. Interestingly, only approximately 55% of the adults who need cholesterol medicine are currently taking any. Healthcare providers can follow the most recent American Heart Association (AHA)/American College of Cardiology (ACC) guidelines, released in 2018, which reinforce the importance of more personalized care for patients, including more detailed personal risk assessments, and present new cholesterol-lowering drug options for highest risk cardiovascular disease (CVD). Also of note is that the risk calculator introduced in the 2013 guidelines is still essential in identifying 10-year CVD risk.
The guidelines promote that the primary measures for avoidance of CVD risk should start early; educate patients to adhere to a healthy lifestyle and to be aware of the risk of high cholesterol levels. Patients with heightened risk factors are those who have a family history of premature atherosclerotic cardiovascular disease (ASCVD). Additionally, a patient’s ethnicity can be a risk factor, such as if they have South Asian ancestry. Certain health conditions can also contribute to CVD risk, specifically chronic kidney disease, chronic inflammatory conditions, metabolic syndrome, high lipid biomarkers, or premature menopause or pre-eclampsia.
Early screening with a family history of early CVD or hyperlipidemia is recommended even in those as young as age 2. Outside of those with risk due to family history, consider initial screening in children aged between 9 to 11 years and then again when they reach 17 to 21 years. The guidelines do not supply specific treatment recommendations for this age group. A benefit from early screening in children is the potential identification of genetic abnormalities in lipid metabolism that may be present in other family members.
Emphasis has been given regarding coronary artery calcium scoring (CAC) as a suggested screening tool. The recommendations now include advisement for CAC exams performed using low dose computed tomography scans. After prescribing LDL-C–lowering medications and having patients implement lifestyle changes, healthcare providers should assess patient adherence and percentage response with repeat lipid measurement. Further guidelines break out the recommended approaches to therapy based on LDL-C level, 10-year ASCVD risk, age, and health history (such as diabetes or other high-risk conditions). In certain circumstances, the addition of ezetimibe may be made to maximally tolerated statin therapy. In other patients at very high risk, the addition of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors alirocumab or evolocumab may be reasonable.
A newer perspective addressed in the guidelines factors in the costs of medications in determining appropriate treatment. In the past, the costs of PCSK9s have contributed to issues with patient access. Cost and related accessibility can have a significant influence on patient adherence. The message that resonates through the guidelines is that personalized care through education, detailed risk assessments, and new drug options are essential considerations in health management. Healthcare providers can take advantage of online tools
and resource information
from the ACC to guide ongoing efforts with managing cardiovascular health in patients.
American College of Cardiology website. Blood Cholesterol: Guideline on the Management of. https://www.acc.org/guidelines/hubs/blood-cholesterol
. Updated November 10, 2018. Accessed December 23, 2019.
Centers for Disease Control and Prevention website. High Cholesterol Facts. https://www.cdc.gov/cholesterol/facts.htm
. Updated February 6, 2019. Accessed December 23, 2019.
Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol, Journal of the American College of Cardiology (2018), doi: https://doi.org/10.1016/j.jacc.2018.11.003
Mercado C, DeSimone AK, Odom E, et al. Prevalence of cholesterol treatment eligibility and medication use among adults—United States, 2005–2012. MMWR