Clinical Edge

Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions

Cholesterol Guidelines Stress Lifetime Approach

Circulation; ePub 2018 Nov 10; Grundy, et al

For people at high risk of cardiovascular disease (CVD), more personalized risk assessments and new cholesterol-lowering treatment options are among the central recommendations in the 2018 cholesterol guidelines from the American Heart Association (AHA) and the American College of Cardiology (ACC). The guidelines also state that a lifetime approach to lowering cholesterol is the key to reducing cardiovascular risk. Among the highlights and recommendations for clinicians:

  • Emphasize a heart-healthy lifestyle across the life course in all individuals.
  • More detailed risk assessments can help determine a patient’s need for cholesterol-lowering treatment, if their risk status is uncertain of if treatment isn’t clear.
  • Statins are still the first choice of treatment for lowering cholesterol.
  • However, new treatment options for high-risk patients include a maximum intensity statin treatment, adding ezetimibe if desired low-density lipoprotein cholesterol (LDL-C) levels aren’t met, and then adding a PCSK9 inhibitor if further cholesterol reduction is needed.


Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol. [Published online ahead of print November 10, 2018]. Circulation. doi:10.1161/CIR.0000000000000625.


The AHA/ACC released new cholesterol-lowering guidelines updating the 2013 report. The new guidelines encourage life-long prevention with lifestyle modification. For individuals under 60 years of age, the pooled-cohort risk equation can estimate a lifetime risk for an ASCVD event. Younger patients may have a low 10-year ASCVD risk and not meet criteria for a statin-benefit group but may have a high lifetime risk. Further risk assessment including the quantification of coronary artery calcium can help with further risk stratification of these individuals and help determine when to start lipid-lowering therapy. In addition, the guidelines suggest that very-high risk patients on maximal statin therapy with an LDL-C greater than 70 mg/dl may benefit from combination lipid-lowering therapy with the addition of ezetimibe or a PCSK9 inhibitor. —Matthew Sorrentino, MD