Applied Evidence

Translating AHA/ACC cholesterol guidelines into meaningful risk reduction

Department of Family Medicine (Dr. Wójcik) and Center for Preventive Cardiology, Knight Cardiovascular Institute (Dr. Shapiro), Oregon Health & Science University, Portland

Dr. Wójcik reported no potential conflict of interest relevant to this article.

Dr. Shapiro serves as a consultant to Amarin Corporation, is on the advisory board of Esperion Therapeutics, Inc., and has contracted research with Akcea Therapeutics, Inc. and The FH Foundation. His work is supported by NIH K12HD043488.

The new recommendations detail refined, personalized lipid management and emphasize multiple levels of evidence. The result? Care is more complex but patients might benefit more.


› Reduce the low-density lipoprotein cholesterol (LDL-C) level in patients with clinical atherosclerotic cardiovascular disease (ASCVD) using high-intensity statin therapy or maximally tolerated statin therapy. A

› Use an LDL-C threshold of 70 mg/dL to prompt consideration of adding nonstatin therapy in patients who have very high-risk ASCVD. A

› Start high-intensity statin therapy in patients who have primary hypercholesterolemia (LDL-C level ≥ 190 mg/dL) without calculating the 10-year ASCVD risk. A

› Begin moderate-intensity statin therapy in patients 40 to 75 years of age who have diabetes mellitus and an LDL-C level ≥ 70 mg/dL without calculating 10-year ASCVD risk. A

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series



A new cholesterol guideline1 builds on the 2013 American College of Cardiology (ACC)/American Heart Association (AHA) cholesterol guidelines,2 which were a major paradigm shift in the evaluation and management of blood cholesterol levels and risk for atherosclerotic cardiovascular disease (ASCVD). The work was presented (and simultaneously published) on November 10, 2018, at the annual AHA Scientific Sessions in Chicago. Full text,1 an executive summary,3 and accompanying systematic review of evidence4 are available online.

The 2018 AHA/ACC cholesterol guideline represents a step forward in ASCVD prevention—especially in primary prevention, where it provides guidance for risk refinement and personalization. In this article, we mine the details of what has changed and what is new in this guideline so that you can prepare to adopt the recommendations in your practice.

Translating AHA/ACC cholesterol guidelines into meaningful risk reduction IMAGE: © JOE GORMAN

2013 and 2018 guidelines: Similarities, differences

As in earlier iterations, the 2018 guideline emphasizes healthy lifestyle across the life-course as the basis of ASCVD prevention—as elaborated in the 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk.5 In contrast to the 2013 guidelines,2 the 2018 guideline is more comprehensive and more personalized, focusing on risk assessment for individual patients, rather than simply providing population-based approaches. Moreover, the guideline isn’t limited to adults: It makes recommendations pertaining to children and adolescents.1

Select major differences between 2013 and 2018 AHA/ACC cholesterol guidelines

TABLE 11,2 compares the most important differences between the 2013 and 2018 guidelines.

Select major differences between 2013 and 2018 AHA/ACC cholesterol guidelines

In contrast to the 2013 guidelines, the 2018 guideline is more comprehensive and more personalized, focusing on risk assessment for individual patients, rather than simply providing population-based approaches.

The 2013 ACC/AHA guidelines eliminated low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol (non-HDL-C)a goals of therapy and replaced them with the concept of 4 “statin benefit groups”—that is, patient populations for which clear evidence supports the role of statin therapy.4 In the 2018 guideline, statin benefit groups have been maintained, although without explicit use of this term.1

Primary prevention. Although no major changes in statin indications are made for patients with (1) established ASCVD (ie, for secondary prevention), (2) diabetes mellitus (DM) and who are 40 to 75 years of age, or (3) a primary LDL-C elevation ≥ 190 mg/dL, significant changes were made for primary prevention patients ages 40 to 75 years.1 ASCVD risk calculation using the 2013 pooled cohort equations (PCE) is still recommended4; however, risk estimation is refined by the use of specific so-called risk-enhancing factors (TABLE 21). In cases in which the risk decision remains uncertain, obtaining the coronary artery calcium (CAC) score (which we’ll describe shortly) using specialized computed tomography (CT) is advised to facilitate the shared physician–patient decision-making process.1

New: Risk-enhancing factors for ASCVD

LDL-C and non-HDL-C thresholds. Although LDL-C and non-HDL-C goals are not overtly brought back from the 2002 National Cholesterol Education Program/Adult Treatment Panel guidelines,6 the new guideline does introduce LDL-C and non-HDL-C thresholds—levels at which adding nonstatin therapy can be considered, in contrast to previous goals to which therapy was titrated. Definitions of statin intensity remain the same: Moderate-intensity statin therapy is expected to reduce the LDL-C level by 30% to 50%; high-intensity statin therapy, by ≥ 50%.1 The intensity of statin therapy has been de-escalated in the intermediate-risk group, where previous guidelines advised high-intensity statin therapy,4 and replaced with moderate-intensity statin therapy (similar to 2016 US Preventive Services Task Force [USPSTF] recommendations7).

Continue to: Fasting vs nonfasting lipid profiles


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