Management of Blood Cholesterol

Publication Date: November 10, 2018

Key Points

Key Points

1. Introduction

  • In all individuals, emphasize a heart-healthy lifestyle across the life course.
  • In patients with clinical ASCVD, reduce low-density lipoprotein cholesterol (LDL-C) with high-intensity statin therapy or maximally tolerated statin therapy.
  • In very high-risk ASCVD, use a LDL-C threshold of 70 mg/dL (1.8 mmol/L) to consider addition of nonstatins to statin therapy. Very high-risk includes a history of multiple major ASCVD events or 1 major ASCVD event and multiple high-risk conditions.
  • In patients with severe primary hypercholesterolemia (LDL-C level ≥190 mg/dL [≥4.9 mmol/L]), begin high-intensity statin therapy without calculating 10-year ASCVD risk.
  • In patients 40 to 75 years of age with diabetes mellitus and LDL-C ≥70 mg/dL (≥1.8 mmol/L), start moderate-intensity statin therapy without calculating 10-year ASCVD risk.
  • In adults 40 to 75 years of age evaluated for primary ASCVD prevention, have a clinician-patient risk discussion before starting statin therapy.
  • In adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dL (≥1.8 mmol/L), at a 10-year ASCVD risk of ≥7.5%, start a moderate-intensity statin if a discussion of treatment options favors statin therapy.
  • In adults 40 to 75 years of age without diabetes mellitus and 10-year risk of 7.5% to 19.9% (intermediate risk), risk-enhancing factors favor initiation of statin therapy.
  • In adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dL to 189 mg/dL (≥1.8–4.9 mmol/L), at a 10-year ASCVD risk of ≥7.5% to 19.9%, if a decision about statin therapy is uncertain, consider measuring coronary artery calcium (CAC).
  • Assess adherence and percentage response to LDL-C–lowering medications and lifestyle changes with repeat lipid measurement 4 to 12 weeks after statin initiation or dose adjustment, repeated every 3 to 12 months as needed.

Diagnosis

Diagnosis

...igh Blood Cholesterol and ASCVD

...nts of LDL-C and Non–HDL-C...

...adults who are 20 years of age or older...

...ts who are 20 years of age or older and in...

...r patients with an LDL-C level less...

4. In adults who are 20 years of age or...


Treatment

...reatment

...Therapeutic Moda...

...id-Lowering Drugs Among lipid-l...

...Moderate-, and Low-Intensity Statin Th...


...tient Management Gro...

.... Secondary ASCVD Pre...

...In patients who are 75 years of age or y...

...with clinical ASCVD in whom high-intens...

...ith clinical ASCVD who are judged to be very...

...ith clinical ASCVD who are judged...

...ients with clinical ASCVD who are on maximally t...

...e Statement 6. At mid-2018 list prices,...

...ients older than 75 years of age w...

...s older than 75 years of age who are t...

...ients with clinical ASCVD who are receiving m...

...ts with heart failure (HF) with reduced e...

...Clinical atherosclerotic cardiovascular...

...Secondary Prevention in Patients Wit...

...2. Very High-Riska of Future ASCVD Even...

...Severe Hypercholesterolemia (LDL-C ≥190 mg...

...s 20 to 75 years of age with an LDL-C l...

...nts 20 to 75 years of age with an LDL-C l...

.... In patients 20 to 75 years of age with a...

4. In patients 30 to 75 years of age with he...

...tients 40 to 75 years of age with a baseline LDL-C...

...nt:6. Among patients with FH witho...

...tes Mellitus in Adults...

...to 75 years of age with diabetes mellitus, rega...

...ts 40 to 75 years of age with diabetes...

...ults with diabetes mellitus who have multipl...

...lts older than 75 years of age with diab...

...In adults with diabetes mellitus and 10-year...

...er than 75 years with diabetes mellitus...

...In adults 20 to 39 years of age with diabetes...

Table 3. Diabetes-Specific Risk Enha...

...ary Prevention...

....4.1. Evaluation and Risk Assessme...

...ure 2. Primary PreventionFigure 2. Primary Pr...

...sk-Enhancing Factors for Clinician–Patient Ris...

...Prevention Adults 40 to 75 Years of Age W...

...adults at intermediate-risk, statin therapy...

...ate-risk patients, LDL-C levels should be r...

...ry prevention of clinical ASCVDa in adult...

...ns and patients should engage in a ris...

...ate-risk adults, risk-enhancing factors favor ini...

...intermediate-risk or selected border...

...te-risk adults or selected borderline-ris...

...rmediate-risk adults who would bene...

...In patients at borderline risk, in risk discu...

...on of clinical aASCVD includes acute coronary...

...ecklist for Clinician–Patient Shared Decision-...

...lected Examples of Candidates for CAC M...

...itoring in Response to LDL-C–Lowering Th...

...Adherence to changes in lifestyle and effec...

....4. Primary Prevention in Other Age Groups

...er Adults Additional recommendations for ad...

...75 years of age or older with an LDL-C level of 7...

...In adults 75 years of age or older, it may...

...adults 76 to 80 years of age with an...

...hildren and Adolescents...

...n children and adolescents with lipid...

2. In children and adolescents with lipid abno...

...en and adolescents 10 years of age or older wi...

...n and adolescents with a family his...

...ildren and adolescents found to have moderate o...

6. In children and adolescents with obe...

...nd adolescents without cardiovascular risk...

...tory of early aCVD is defined here as MI,...

...mal and Abnormal Lipid Values in Childhooda...

...her Populations at Risk...

...ity1. For clinical decision-making in adults of di...

...ial/Ethnic Issues in Evaluation, Risk Decisions,...

...Hypertriglyceridemia...

...dults 20 years of age or older with moderate h...

...adults 40 to 75 years of age with moderate or se...

...ts 40 to 75 years of age with severe h...

...adults with severe hypertriglyceridemia (fasting...

...Issues Specific to Women...

...should consider conditions specific to...

...childbearing age who are treated with statin...

...f childbearing age with hypercholesterolemia who...

....5.4 Adults With...

...0 to 75 years of age with LDL-C 70 to 189 mg...

2. In adults with advanced kidney disea...

...h advanced kidney disease who require...

...dults With Chronic Inflammatory Disorders...

...40 to 75 years of age with LDL-C 70 to 189...

...n patients with chronic inflammatory d...

...dults with RA who undergo ASCVD risk as...


...Safety and Statin-Associated Side Effects...

...cian-patient risk discussion is recom...

...n patients with statin-associated muscle symptoms...

...patients with indication for statin therapy,...

...s with statin-associated side effects that are...

...In patients with increased diabetes...

...In patients treated with statins, it is recomme...

...In patients at increased ASCVD risk with chron...

...atients at increased ASCVD risk with se...

...is NOT recommended for routine use in patients tre...

...tients treated with statins, routine m...

.... Statin-Associated Side Effects (SASE)...


...plementation

...ventions focused on improving adherence to presc...

...ns, health systems, and health plans...

3. Before therapy is prescribed, a patient...

...Effectiveness Analysis for PCSK9 Inhibi...