New Treatment Guidelines for High Cholesterol: What You Should Know

Karen Aspry, MD

In November, the American Heart Association held its annual scientific sessions, and released the first new cholesterol treatment guideline in five years. Here are the five things you should know now to lower your risk of heart attack and stroke from cholesterol and other factors. This information updates the recommendations regarding risk assessment and treatment discussed in my earlier blog

1. Prevention experts are in agreement about cholesterol.

The 2018 cholesterol treatment guideline published by the American Heart Association and American College of Cardiology was endorsed by 10 other medical societies. This means there is now good agreement among prevention experts about when and how to treat cholesterol to reduce a person’s risk of atherosclerotic cardiovascular disease (ASCVD).  ASCVD is cholesterol build-up in the arteries, and is the cause of heart attacks, peripheral artery disease (PAD), stents, bypass graft surgery, and most strokes.

2. Diet and lifestyle remain the foundation of heart health!

No matter what your cholesterol level is, a healthy diet and lifestyle will reduce your risk. So, eat fruits and vegetables, whole grains, lean proteins (especially beans and other plant proteins), and healthy fats like olive oil.  Ditch foods high in saturated fat, added sugars and sodium. Also get at least 150 minutes per week of moderate intensity exercise, lose weight if you’re overweight, and don’t smoke or vape.  Encourage these habits in kids too, because ASCVD starts early!

3. What the new guidelines say.

  • If you have ASCVD already, a high intensity statin is recommended to reduce your “bad” LDL-cholesterol (LDL-C) by at least 50 percent, which will reduce your risk of heart attack by that same amount.  A moderate intensity statin can be taken if you’re over age 75. If you have had a recent or multiple heart attacks, stents, or bypass, or you have PAD and other risk factors, the expert guidelines recommend you lower your bad LDL-cholesterol to less than 70mg/dl. This can be done with more intensive diet and lifestyle changes and, if needed, adding other medications.
  • If you have diabetes and are age 40-75, a moderate or high intensity statin is recommended to reduce your risk.
  • If you have very high LDL-cholesterol of greater than 190 mg/dl at age 20 or older, when not due to another cause, a high-intensity statin is recommended to lower LDL-cholesterol (LDL-C) by 50 percent and to under 100 mg/dl.  If you can’t get to this number, ezetimibe and then a PCSK9 inhibitor can be added if it looks like you have familial hypercholesterolemia (FH).  Go to the FH Foundation website for more info on this unrecognized disorder.
  • In children ages 0-19, if FH is diagnosed, a statin along with diet and exercise can be safely started at age 10 to reduce future risk.  
  • If you don’t have any of the above but are age 20-39, it is now recommended that you estimate your 10-year risk of ASCVD using the free ASCVD Plus Risk Estimator or ask your primary care provider to estimate your risk. Then consider a statin if your LDL-C is 160 mg/dl or more, and you have a family history of early heart disease or elevated lifetime risk.
  • If you don’t have any of the above but are age 40-75, it is recommended that you calculate your 10-year risk of ASCVD using the free ASCVD Plus Risk Estimator.  This is important – it is no longer enough for you or your primary care provider to look at your cholesterol numbers and try to “guess” if you are at elevated risk.

Your calculated risk:

To calculate your 10-year ASCVD risk use the risk estimator from the Amercian Callege of Cardiology.

  • If your calculated 10-year risk is between 5 and 7.5 percent, consider a statin if you have "risk-enhancing" factors like South Asian ancestry, inflammatory diseases like HIV or rheumatoid arthritis, metabolic syndrome, chronic kidney disease, a history (in women) of preeclampsia or early menopause, family history of early heart disease, or other lipid risk factors. These include an LDL-C of 160 mg/dl or greater, triglycerides of 175 mg/dl or greater, or high levels of other lipid risk factors.
  • If your calculated 10-year risk is between 7.5 and 20 percent, a statin is recommended. If you want proof of your risk before taking a statin, obtain a Coronary Artery Calcium (CAC) score test. This quick CAT scan involves no IV and costs about $100. If your CAC is zero, a statin may be deferred as long as you don’t smoke or have diabetes or a family history of ASCVD. A statin is favored or recommended if your CAC score is positive, depending on the score.
  • If your calculated 10-year risk is 20 percent or greater, a high intensity statin is recommended to lower LDL-C by at least 50 percent.    
  • Always discuss your risks, and the pros and cons of taking a statin, with your provider.

4. Non-fasting cholesterol levels are okay for most.

It’s important to have your cholesterol rechecked after starting or changing cholesterol medication, but don’t worry if you cannot fast. Non-fasting cholesterol levels will show higher triglycerides, but LDL-cholesterol won’t usually be affected. Most of the time the lab can still calculate or directly measure your LDL-cholesterol if you get it checked without fasting. In some cases you may need to return to the lab after fasting. 

5. Relax.

Knowing that you’re doing everything you can to reduce your heart disease and stroke risks! You can learn more about your cholesterol and its effects here

Learn more about the Lifespan Cardiovascular Institute at Rhode Island, The Miriam and Newport hospitals.

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