Individualized Risk Assessment, New LDL-lowering Options Among Highlights in 2018 AHA/ACC Cholesterol Guidelines

Personalized risk assessments and new cholesterol-lowering therapies were among the new key recommendation of the American Heart Association/American College of Cardiology 2018 Cholesterol Guidelines, presented at the American Heart Association 2018 Scientific Sessions in Chicago.

“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 (CVD),” said Ivor Benjamin, MD, FAHA, president of the American Heart Association, in a press release. “Having high cholesterol at any age increases that risk significantly. That’s why it’s so important that even at a young age, people follow a heart-heathy lifestyle and understand and maintain healthy cholesterol levels.”

The guidelines contained several updates and tools practitioners can use. The CVD risk calculator, introduced in the 2013 guidelines, is an essential tool in the armamentarium for identifying a patient’s 10-year risk for CVD. The 2018 guidelines encourage practitioners, in addition to following the results of the risk calculator, to talk with their patients about “risk-enhancing factors,” with the goal of providing a more personalized risk perspective. Some of these risk-enhancing factors include family history, ethnicity, conditions like metabolic syndrome, chronic kidney disease, inflammatory conditions, menopause, preeclampsia and high lipid markers.

For high-risk patients with previous MI or stroke and whose elevated LDL-C levels are not well controlled by statin therapy, the 2018 guidelines make a recommendation for a step-wise for ezetimibe, added to a statin regimen, and then a PCSK9 inhibitor if ezetimibe is not working. One potential hurdle noted was the cost of PCSK9 inhibitors, which insurers have been slow to cover.  In an encouraging sign, Dr. Benjamin reported that this may be beginning to change.

“The Association is bringing together stakeholders to discuss financial barriers to the care of heart disease and stroke,” he said in a press release. “We have been heartened that drug makers have recently agreed to reduce the prices of PSCK9 inhibitors and are making arrangements with payors to ease the financial burden for patients who could benefit from the additional medication options.”

Other important take-home messages from the 2018 guidelines included continual emphasis on a heart-healthy lifestyle across life course and an increased emphasis on the use of coronary artery calcium scores in certain patients who are

The guidelines were published along with a special companion report summarizing the rationale and evidence for quantitative risk assessment. The report also reviewed the limitations and strengths of risk scores, discussed individualized risk assessment approaches, and provided advice for risk assessment and decision-making strategies in clinical practice.

Read the full AHA/ACC 2018 Cholesterol Guidelines in Circulation or JACC.