November 10, 2018

AHA and ACC Publish 2018 Cholesterol Guidelines

November 10, 2018—The American Heart Association (AHA) and American College of Cardiology (ACC) announced the publication of 2018 cholesterol guidelines recommending more personalized risk assessments and new cholesterol-lowering drug options for those at highest risk for cardiovascular disease.

The guidelines were presented at the AHA's 2018 scientific sessions held November 10–12 in Chicago, Illinois. The guidelines by Scott M. Grundy, MD, et al were simultaneously published online in Circulation and Journal of the American College of Cardiology (JACC).

As summarized in the AHA/ACC announcement, highlights of the guidelines are as follows:

  • High cholesterol, at any age, can increase a person’s lifetime risk for heart disease and stroke. A healthy lifestyle is the first step in prevention and treatment to lower that risk.
  • The 2018 guidelines recommend more detailed risk assessments to help health care providers better determine a patient's individualized risk and treatment options.
  • In some cases, a coronary artery calcium score can help determine one's need for cholesterol-lowering treatment, if their risk status is uncertain or if the treatment decision isn't clear.
  • Although statins are still the first choice of medication for lowering cholesterol, new drug options are available for patients who have already had a heart attack or stroke and are at highest risk for recurrence. For those patients, medication should be prescribed in a stepped approach, first with a maximum intensity statin treatment, adding ezetimibe if desired LDL cholesterol levels aren’t met and then adding a PCSK9 inhibitor if further cholesterol reduction is needed.

In the announcement, AHA President Ivor Benjamin, MD, commented, “The updated guidelines reinforce the importance of healthy living, lifestyle modification, and prevention. They build on the major shift we made in our 2013 cholesterol recommendations to focus on identifying and addressing lifetime risks for cardiovascular disease. Having high cholesterol at any age increases that risk significantly. That’s why it’s so important that even at a young age, people follow a heart-heathy lifestyle and understand and maintain healthy cholesterol levels.”

Michael Valentine, MD, President of ACC, added, “High cholesterol treatment is not one size fits all, and this guideline strongly establishes the importance of personalized care. Over the past 5 years, we’ve learned even more about new treatment options and which patients may benefit from them. By providing a treatment road map for clinicians, we are giving them the tools to help their patients understand and manage their risk and live longer, healthier lives."

As a companion to the cholesterol guidelines, a special report by Donald M. Lloyd-Jones, MD, et al was published online in Circulation and JACC and provides a more detailed perspective about the use of quantitative risk assessment in primary prevention for cardiovascular disease. The risk calculator introduced in the 2013 guidelines remains an essential tool to help health care providers identify a patient’s 10-year risk for cardiovascular disease.

“There have been concerns over the cost of PCSK9 inhibitors and some insurance companies have been slow to cover them, so it’s important to note that the economic value of these new medications may be substantial only for a very specific group of people for whom other treatments haven’t worked,” Benjamin said. “The Association is bringing together stakeholders to discuss financial barriers to the care of heart disease and stroke. We have been heartened that drug makers have recently agreed to reduce the prices of PSCK9 inhibitors and are making arrangements with payors to ease the financial burden for patients who could benefit from the additional medication options.”

“The College has long recognized that the cost of PCSK9s have made patient access an issue. We are committed to helping physicians with access to care issues, while also bringing together stakeholders, including payer, industry, and clinician representatives, to talk about opportunities to move forward together,” Valentine said. “Our goal is to make sure the highest-risk patients have access to the care they need.”


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