ACC/AHA Guidelines on the Management of Blood Cholesterol: What You Need to Know

1. Adopt a heart-healthy lifestyle

People of all ages can reduce their risk of ASCVD by adopting a heart-healthy lifestyle. This includes:

• getting enough physical activity
• getting enough good sleep
• eating a heart-healthy diet
• maintaining a moderate weight
• quitting smoking if you do

A heart-healthy lifestyle also helps prevent metabolic syndrome, a risk factor for heart disease.

If you are between 20 and 39 years old, a heart-healthy lifestyle is key to reducing risk. It’s also important to know your risk factors and talk with your doctor about how to address them.

2. Use statins to help reduce levels of ‘bad’ cholesterol

Low-density lipoprotein cholesterol (LDL-C) is sometimes called “the bad cholesterol.” If you have clinical ASCVD, the ACC/AHA guidelines recommend using statins to lower your LDL-C levels. Statins block an enzyme your liver uses to make cholesterol.

The guidelines suggest using high intensity statins (or the highest level you can tolerate) to reduce your LDL-C levels by 50% or more.

3. Those at high risk might benefit from nonstatins

If you are in a very high risk category for ASCVD, your doctor may prescribe nonstatin medication to take with your statins.

When your LDL-C remains above 70 mg/dL, your doctor may prescribe ezetimibe (Zetia) in addition to the strongest statin you can tolerate. It’s a tablet you take by mouth.

If that combination does not bring your level below 70 mg/dL, guidelines suggest adding a PCSK9 inhibitor. But there are some drawbacks to these. They’re often costly, and there’s little data to support their long-term safety.

4. People with severe primary hypercholesterolemia should take high intensity statins

Primary hypercholesterolemia is typically inherited and not due to environmental factors. It’s also called familial hypercholesterolemia. The ACC and AHA define severe primary hypercholesterolemia as an LDL-C level equal to or above 190 mg/dL.

For people in this group, the guidelines recommend that doctors start high intensity statin therapy. If your LDL-C level remains above 100 mg/dL with therapy, they recommend adding ezetimibe. But if both medications don’t bring it below that level, talk with your healthcare team about adding a PCSK9 inhibitor.

5. Mature and older adults with diabetes should start moderate statin therapy

For some adults, doctors may recommend moderate-intensity statins without doing a risk assessment. Specific conditions include:

• You are between 40 and 75 years old.
• You have diabetes.
• You have an LDL-C level of 70 mg/dL or higher.

Your doctor may recommend a high intensity statin if you are 50 years or older and have diabetes, especially if you have multiple risk factors.

6. Other mature and older adults should have a risk discussion before taking statins

If you are 40 to 75 years old and your doctor has evaluated you for primary ASCVD prevention, the guidelines recommend having a detailed discussion with your healthcare team before taking statins.

The discussion may include talking about your risk factors, such as:

• cigarette smoking
• hypertension
• elevated LDL-C
• A1C results (if you have them)

You may also want to talk about:

• any necessary lifestyle changes
• the cost of statin therapy
• drug interactions
• your preferences and values

All of these lead to shared decision making when determining your treatment plan.

Because the discussion may include numerous details and take a lot of time, your doctor may have you speak with a trained staff member for referral to specialists or others who can help with treatment.

7. Some mature and older adults without diabetes should start moderate statin therapy

Your doctor may recommend taking moderate-intensity statins if:

• You are between 40 and 75 years old.
• You don’t have diabetes.
• Your LDL-C levels are at or above 70 mg/dL.
• You have a 10-year ASCVD risk at or greater than 7.5%.

The goal of statin therapy is to reduce your LDL-C by at least 30%. If your 10-year risk is 20% or higher, the goal is to reduce your LDL-C level by 50% or more. If you have high risk factors, you may need high intensity statins.

8. Certain risk factors may suggest some adults could benefit from statins

If you are 40 to 75 years old, don’t have diabetes and your 10-year risk is between 5% and 19.9%, certain factors may increase your risk. These factors might cause your doctor to prescribe statins. Factors include:

• a family history of premature ASCVD
• persistent elevation of LDL-C levels (equal to or above 160 mg/dL)
• metabolic syndrome or chronic kidney disease
• a history of preeclampsia or premature menopause (under 40 years old)
• chronic inflammatory disorders like rheumatoid arthritis, psoriasis, or chronic HIV
• inclusion in a high risk ethnic group
• persistent elevation of triglyceride levels (equal to or above 175 mg/dL)
• systemic lupus
• having had radiation treatment that includes part of your heart and arteries, such as that used to treat breast cancer

9. If uncertain about risk, check calcium levels

If your ASCVD risk is between 7.5% and 19.9%, but doctors still aren’t certain about statins, they may take your coronary artery calcium score (CAC). This allows them to see how much calcium has built up in your arteries.

If your score is 0 and you are not a smoker or don’t have a strong family history of premature ASCVD, you may not need statins.

Helpful tip

Your insurance carrier may not pay for a CAC test, which can cost between $75 and $350. Still, the test may be helpful in deciding on long-term treatment, even if you don’t have any symptoms.

10. Doctors should regularly monitor your response to therapy and lifestyle changes

Once you start a treatment plan, your doctor should measure your lipids regularly to see how well your lifestyle changes and statin therapy are working. They should check your LDL-C levels 4 to 12 weeks after you start or change your statin therapy, and then every 3 to 12 months as needed.

Doctors consider you to be in a very high risk group if you have or have had:

• a history of multiple major ASCVD events such as acute coronary syndrome in the past year
• a heart attack
• ischemic stroke
• peripheral arterial disease
• a major event with multiple high risk conditions

Those high risk conditions include, but aren’t limited to:

• being 65 or older
• smoking
• having had heart surgery to improve blood flow to your heart
• diabetes
• chronic kidney disease
• heterozygous familial hypercholesterolemia (HeFH)

The guidelines also consider ethnicity when looking at risk factors for high cholesterol and ASCVD.

Several groups are at greater risk for dyslipidemia than white people. It’s important to consider how a sedentary lifestyle and dietary traditions affect risk.

For the following groups, the guidelines recommend lifestyle counseling, with racial and ethnic preferences in mind, to address weight gain, blood pressure, and lipids.

Asian Americans

The risk for people of East and South Asian origin varies by country of descent. It’s higher in those from South Asia, including:

• Bangladesh
• India
• Nepal
• Pakistan
• Sri Lanka

Countries of East Asian origin include Japan, the Koreas, and China.

Asian Americans as a whole show lower levels of HDL-C, or “good cholesterol,” than white people. Asian Indian, Filipino, Japanese, and Vietnamese people tend to have higher LDL-C levels than white people.

All subgroups showed an increased prevalence of high triglycerides.

Asian Americans also tend to develop metabolic syndrome at a lower waist circumference than white people. Asian Americans also tend to develop diabetes at a lower lean body mass and earlier age. Diabetes and metabolic syndrome are risk factors for heart disease.

Hispanic or Latinx Americans

Race, country of origin, and socioeconomic status all affect Hispanic and Latinx people differently. For instance, people of Puerto Rican descent have an increased ASCVD risk than those of Mexican descent.

However, Hispanic and Latina females as a whole are more likely to have low HDL than Hispanic and Latino males. All Hispanic and Latinx groups are more likely to have diabetes than white people. Mexican Americans are also more likely to have metabolic syndrome than Puerto Ricans and white people.

Black Americans

Black females are more at risk of ASCVD than their similar, white counterparts.

Black people tend to have higher levels of HDL-C and lower levels of triglycerides than non-Hispanic white people or Mexican Americans.

Black people also tend to have a higher risk for diabetes and hypertension. Both are risk factors for cardiovascular disease.

It’s good to have an in-depth discussion with your healthcare team about your cholesterol and risk of developing ASCVD. Many of the guidelines call for a 10-year risk assessment, but there are some other important topics to cover.

They include:

• family history of high cholesterol and heart disease
• medical history
• smoking
• other conditions you may have
• what medications you are taking
• what medicines are most cost-effective for you to take
• your values and preferences
• your diet and exercise habits
• what medication side effects you may be experiencing

The 2018 Guideline on the Management of Blood Cholesterol contains the most recent recommendations for helping you manage high blood cholesterol to avoid heart problems, specifically ASCVD.

Recommendations for lifestyle changes and drug therapy vary depending on your age, cholesterol level, family history, lifestyle, and diet. They may also depend on what other medications you take.

It’s important to have a detailed discussion with your doctor about these topics and to evaluate your risk for developing ASCVD. People in certain ethnic groups are at a higher risk for ASCVD than their white counterparts.

Many lifestyle changes and medications can help you get your cholesterol under control and reduce your risk for serious heart disease. Lifestyle changes are the most important step to take. Making the right changes for long enough could mean taking less, or no, medication.