A working group composed of two Johns Hopkins Medicine physicians and their American Heart Association colleagues has released updated clinician guidelines on managing cholesterol as a way to minimize risk for heart attack, stroke and death.

The new recommendations, released at the 2018 American Heart Association Scientific Sessions on Nov. 10 in Chicago, advocate for more aggressive treatment with statin therapy in specific instances, while also encouraging a more personalized approach that addresses a heart-healthy lifestyle and better collaboration in decision-making between clinicians and their patients. The guidelines incorporate new research findings since the last guidelines were released in 2013.

“These new guidelines do an excellent job of dealing with the shortcomings of the 2013 guidelines and add great new science that we’ve uncovered,” says Roger Blumenthal, M.D., the Kenneth Jay Pollin Professor in Cardiology at the Johns Hopkins University School of Medicine and director of the Ciccarone Center for the Prevention of Cardiovascular Disease. “There’s a greater emphasis on lifestyle, risk assessment improvements and strong treatment benefits for those at high risk for having a future life-threatening cardiovascular event.”

Based on the newest research, experts now believe that lowering “bad” cholesterol—known as low-density lipoprotein (LDL) cholesterol—to levels less than 70 milligrams per deciliter in high risk patients is best for reducing heart disease complications and risk of dying. An LDL-cholesterol level more than 160 is considered very high. A simple blood draw during a visit to the doctor and analysis by a lab can determine cholesterol levels.

High cholesterol is one of several controllable risk factors that can increase a person’s chance of heart disease. The factors also include being overweight, smoking, diabetes, high blood pressure, not getting enough exercise and more. Clinicians use risk factor calculations that determine heart disease and stroke risk by factoring in other items such as age race and the other risk factors associated with high cholesterol, giving an estimated risk of having a major cardiovascular (heart or vascular) event in the next 10 years. High risk is classified as at least a 20 percent chance of having a heart attack or stroke in the next decade. Intermediate risk is a 7.5–19.9 percent chance over the next decade.

While poor diet, little exercise and being overweight can increase LDL-cholesterol levels, genetics plays a role too. If a parent or sibling has high cholesterol or heart disease, the patient should be more concerned about these conditions. Cholesterol levels also increase as a person gets older.

The authors of the guidelines have condensed the recommendations into 10 key messages aimed at clinicians:

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 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 Martin and 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.

“Our goal with these new guidelines is to not only reduce heart attacks and stroke, but to also reduce the need for angioplasties and the incidence of peripheral arterial disease too, which traditionally haven’t received as much attention from clinicians as life-threatening acute vascular events,” says Chiadi Ndumele, M.D., M.H.S., the Robert E. Meyerhoff Assistant Professor at the Johns Hopkins University School of Medicine. Peripheral arterial disease is narrowing or blocking of blood vessels from the heart to the legs. About 8.5 million people in the U.S. have the condition, which can make it painful to walk.

Cardiovascular disease kills one in three Americans, including 836,000 people each year, according to the American Heart Association. Also, more than 700,000 Americans have heart attacks each year. The leading cause of death for women in the U.S. is heart disease, which includes heart attack, heart failure, irregular heartbeat or stroke.
 

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On the Web:

• 3 Myths About Cholesterol-Lowering Statin Drugs
• New Cholesterol Calculation May Avoid Need to Fast Before Testing, Study Suggests
• Commonly Used Cholesterol Calculation Underestimates the Heart Disease Danger for Many at High Risk, Study Finds
• Alcohol Use Affects Levels of Cholesterol Regulator Through Epigenetics