The American College of Cardiology and the American Heart Association released updated cholesterol guidelines at the #AHA18 Scientific Sessions. This is the first major update to the guidelines since 2013.

While most of the guidelines remain the same, they now include a new category for patients with high-risk atherosclerotic cardiovascular disease (ASCVD), which is one of the leading causes of illness and early death. Patients in the new high-risk category have either had a previous major ASCVD event or have had repeated major ASCVD events while using therapies that were within the guidelines, in addition to having multiple risk factors. For high-risk patients, the updated guidelines should improve access to treatments or medications that may have been difficult to receive in the past.

What Is Atherosclerotic Cardiovascular Disease?

ASCVD, also known as atherosclerosis, occurs when plaque buildup causes the arteries to harden and narrow. Arteries are blood vessels that carry oxygen-rich blood from the heart throughout the body. Plaque is made up of calcium, cholesterol, fat and other substances that are found in the blood. ASCVD can be caused by high blood pressure, high cholesterol or smoking, and the condition can cause a heart attack or stroke.

Why Did the Cholesterol Guidelines Change?

Pradeep Natarajan, MD, MMSc, director of Massachusetts General Hospital's Preventive Cardiology Program, says preventing ASCVD from developing or preventing it from happening again in the future is a key focus of cardiovascular medicine. One of the main strategies for preventing ASCVD is to lower plasma cholesterol, which is why the new guidelines were released.

The guidelines were updated to include recommendations for non-statin medicines, which have been shown to reduce the risk of recurrent cardiovascular disease. These include ezetimibe and PCSK9 inhibitors, both of which lower low-density lipoprotein (LDL) levels. LDL is known as "bad" cholesterol because it can build up in the arteries and cause a heart attack or stroke. Both ezetimibe and a PCSK9 inhibitor can be used alone or with a statin, which is a drug that reduces fat levels in the blood.

The updated guidelines also provide more detail about when physicians should consider prescribing PSCK9 inhibitors. This may expand access for patients who could benefit from more aggressive LDL lowering because, according to Dr. Natarajan, the new guidelines provide more clarity about when to consider PSCK9 inhibitors than the current Food and Drug Administration labels for these medicines.

How Is Risk Categorized in the Updated Guidelines?

Identifying suitable statin candidates who did not already have high cholesterol or diabetes in order to prevent a first ASCVD event was challenging with the 2013 guidelines, Dr. Natarajan says. He explains that with the updated guidelines, there is more emphasis on shared decision-making between intermediate-risk patients and providers to determine statin suitability. This means patients will work with their health care provider to decide if statins are the best treatment option. The updated guidelines incorporate "risk enhancing" factors that were previously outlined in 2013, such as family history, and also include several new factors, including:

  • Chronic inflammatory illness
  • History of preeclampsia
  • History of premature menopause
  • South Asian ancestry

What Do the Updated Guidelines Mean for Patients?

In addition to emphasizing shared decision-making for patients with an intermediate risk, the updated cholesterol guidelines open the door for a referral to preventive cardiology, according to Dr. Natarajan. Risk assessments will also be more detailed and personalized because patients will be able to review the "risk enhancing" factors with their health care provider. And finally, patients who have had a stroke or heart attack and are at the highest risk of having another but would not benefit from using statins to lower their LDL can now be prescribed other medications instead.