Updated 2018 Cholesterol Guidelines for Heart Health

Johns Hopkins Medicine physicians and their American Heart Association colleagues released updated clinician guidelines on managing cholesterol as a way to minimize risk for heart attack, stroke and death on Nov. 10, 2018. The guidelines’ authors have provided the following 10 takeaway messages for health care providers:

1. Encourage your patients to have a more heart-healthy lifestyle with good diet and exercise habits, and start young. Prevent controllable risk factors such as weight gain, and help patients quit smoking. Lifestyle change is the primary therapy for people with metabolic syndrome, a cluster of risk factors - high blood pressure, high blood sugar, and abnormal cholesterol or triglyceride levels linked to obesity - that is associated with increased cardiovascular disease risk. The longer patients stay healthy, the longer they can keep their cholesterol levels under control and minimize the chance of developing high blood pressure or diabetes.
2. Numbers matter, and lower LDL-cholesterol numbers are better. For patients who have already had a heart attack, stroke or other episode indicating cardiovascular disease, clinicians should prescribe the maximum tolerated statin therapy to decrease the risk of future life-threatening events. (New guidelines now support using the Martin/Hopkins method, developed by Seth Martin, M.D. M.H.S., for calculating cholesterol, especially when triglycerides (blood fats) are elevated or LDL cholesterol is low.)
3. For patients with a known history of heart disease, clinicians should first try adding the cholesterol-lowering drug ezetimibe (a statin) to the maximum tolerated dose if cholesterol levels are 70 or more. Reevaluate after four to 12 weeks to see if newer drugs called PCSK9 inhibitors may be needed to get bad cholesterol levels below 70 in very high risk patients. (Based partly on research by Seth Martinand Steve Jones, M.D.)
4. Treat people with the genetic condition familial hypercholesterolemia sooner rather than later, especially if their LDL cholesterol is more than 190 milligrams per deciliter on two occasions. Get their cholesterol levels down by half—to under 100 if possible—with statin therapy, and if needed add ezetimibe, or consider PCSK9 inhibitor therapy if LDL-cholesterol levels are still 100 or greater. Discuss lifestyle changes at every doctor’s visit.
5. The new guidelines recommend that clinicians start statin treatment in adults with type 2 diabetes who have LDL-cholesterol levels of 70 or more. However, Johns Hopkins physicians feel that some patients with type 2 diabetes can first work harder on lifestyle for six months before going on lifelong statin treatment. Studies that they have collaborated on have shown that 35 percent of people with type 2 diabetes will be at very low heart disease risk over the next decade if they have been shown to have no calcium buildup in their coronary arteries. A coronary artery calcium scan could help determine if statins are necessary for those with diabetes. (Based on work by Michael Blaha, M.D., M.P.H. See number 9 on this list)
6. While the patient is the final decision maker, clinicians need to work with their patients and discuss lifestyle, risk and medication to help guide the decision-making process, since risk factors alone do not require statin. If the person has a couple of risk factors but is on the fence about taking a statin, it might be worth having a coronary artery scan to show their actual risk of disease. Clinicians should also keep in mind that people with an autoimmune or inflammatory condition such as psoriasis, HIV, rheumatoid arthritis or lupus are at higher risk of heart disease and need to work harder at lifestyle improvements. If their cholesterol numbers remain elevated, they should discuss statin therapy with their clinician. (Based on work by Seamus Whelton, M.D., M.P.H.)
7. Patients age midlife or older with a 10 year cardiovascular disease risk of 7.5 percent or more are recommended to discuss starting a statin with their clinician and aim for at least a 30 percent cholesterol reduction, or a 50 percent reduction in high risk patients.
8. Clinicians should also keep in mind that certain risk factors hold more weight, such as persistently high LDL cholesterol above 160, chronic kidney disease, a family history of coronary disease, South Asian descent or other factors in determining whether a statin is appropriate. Women have particular factors placing them more at risk, such as early menopause, preeclampsia and higher triglyceride levels. (Pamela Ouyang, M.D., and Erin Michos, M.D., M.H.S., have written on this.)
9. Newly incorporated into the guidelines is the coronary artery calcium scan, which can more accurately assess heart disease risk when clinicians can’t determine whether a patient needs a statin or can continue to focus solely on lifestyle modifications. A 0 score on a coronary artery calcium scan can suggest that a person has a low 10 year heart disease risk and would get less benefit from adding a statin. A coronary artery calcium score higher than 100 means the patient has heart disease, is at risk of a life-threatening event and should probably start taking a statin. A coronary artery calcium scan costs about $75–$100. (Studies by Michael Blaha.) Having any coronary artery calcium strengthens the case for going on statin therapy.
10. After starting a patient on a statin, clinicians should aim to recheck their cholesterol levels after a month or two to assess if it’s working, if the dosage needs adjusting or if the patient is still taking the medicine. The statin should lower cholesterol levels by at least 30 percent after about a month. Continue to measure cholesterol each year.
11. To learn more view the executive summary of the guidelines written by Seth Martin and Roger Blumenthal.