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

Diagnosi...

2. High Blood Cholesterol...

....1. Measurements of LDL-C and Non–HDL-C...

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

...dults who are 20 years of age or ol...

...or patients with an LDL-C level less than...

...are 20 years of age or older and without a...


Treatment

...reatmen...

...Therapeutic Modalities...

...ing Drugs Among lipid-lowering d...

...able 1 High-, Moderate-, and Low-Intensity St...


...t Management Groups...

...1. Secondary ASCVD Preve...

...patients who are 75 years of age or younger wi...

...In patients with clinical ASCVD in...

...ents with clinical ASCVD who are judged to...

...with clinical ASCVD who are judged to be very h...

5. In patients with clinical ASCVD who are on...

...ue Statement 6. At mid-2018 list p...

...patients older than 75 years of age with cli...

...older than 75 years of age who ar...

...ents with clinical ASCVD who are receiving...

...with heart failure (HF) with reduced ej...

...Clinical atherosclerotic cardiovascul...

...condary Prevention in Patients With Clinical ASC...

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

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

...In patients 20 to 75 years of age w...

...atients 20 to 75 years of age with an LDL-C lev...

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

...atients 30 to 75 years of age with hetero...

...patients 40 to 75 years of age with a basel...

...ue Statement:6. Among patients with FH...

...tes Mellitus in Adults...

...lts 40 to 75 years of age with diabetes mellitus,...

...s 40 to 75 years of age with diabetes mellitu...

...adults with diabetes mellitus who have multiple...

...older than 75 years of age with diabetes mellitu...

...adults with diabetes mellitus and 10-ye...

...lts older than 75 years with diabetes mellitus, it...

...s 20 to 39 years of age with diabe...

...abetes-Specific Risk Enhancers That Are Ind...

...Primary Prevention...

....1. Evaluation and Risk AssessmentMod...

...gure 2. Primary PreventionFigure 2. Primary Pre...

...Risk-Enhancing Factors for Clinician–Pat...

...revention Adults 40 to 75 Years of Age...

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

...te-risk patients, LDL-C levels should be reduc...

...the primary prevention of clinical ASCVDa in adult...

...nd patients should engage in a risk d...

...intermediate-risk adults, risk-enhancing f...

...te-risk or selected borderline-risk adults, if...

...n intermediate-risk adults or selected bo...

.... In intermediate-risk adults who w...

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

...ion of clinical aASCVD includes acute coronary...

Table 5. Checklist for Clinician–Patient...

...lected Examples of Candidates for CAC Measureme...

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

...Adherence to changes in lifestyle and effect...

4.4.4. Primary Prevention in Oth...

...Adults Additional recommendations...

...dults 75 years of age or older with an LDL-C leve...

...n adults 75 years of age or older, it may be...

...ults 76 to 80 years of age with an LDL...

....4.2. Children and Adol...

...and adolescents with lipid disorders related to ob...

2. In children and adolescents with lipi...

...and adolescents 10 years of age or older w...

...n children and adolescents with a family...

5. In children and adolescents found to have...

...nd adolescents with obesity or othe...

...ren and adolescents without cardiovascular risk f...

...y history of early aCVD is defined here a...

...Normal and Abnormal Lipid Values in Childhooda...

.... Other Populations at Risk...

...or clinical decision-making in adults of different...

...acial/Ethnic Issues in Evaluation,...

....5.2. Hypertriglyceride...

...ults 20 years of age or older with mo...

...dults 40 to 75 years of age with moderate or...

...In adults 40 to 75 years of age wit...

...n adults with severe hypertriglyceridemia (fas...

4.5.3. Issues Specific to Wome...

...s should consider conditions specific...

...childbearing age who are treated w...

...omen of childbearing age with hypercholesterolem...

....4 Adults With CKD

...ults 40 to 75 years of age with LDL-C 7...

...ts with advanced kidney disease that requires...

...In adults with advanced kidney disease wh...

...ts With Chronic Inflammatory Disorders and HI...

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

...ents with chronic inflammatory dis...

...ults with RA who undergo ASCVD risk assessment...


.... Statin Safety and Statin-Associated Side Effe...

...ian-patient risk discussion is rec...

.... In patients with statin-associated muscle...

...In patients with indication for statin...

...tients with statin-associated side...

...with increased diabetes mellitus risk or new-ons...

...patients treated with statins, it is recom...

...ients at increased ASCVD risk with chronic, stabl...

...s at increased ASCVD risk with severe statin-...

...is NOT recommended for routine use in p...

...atients treated with statins, routine m...

...ble 9. Statin-Associated Side Effects (...


.... Implementa...

...nterventions focused on improving adher...

...nicians, health systems, and health plans sh...

...therapy is prescribed, a patient-clinician...

...Cost-Effectiveness Analysis for PCSK9 Inhibi...