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New Cholesterol Treatment Guidelines

Although it has gotten much press already, some interesting facts about cholesterol treatment were presented last year in an update to US guidelines for cholesterol management from the American Heart Association and the American College of Cardiology. Dr's. Scott Grundy and Neil Stone, leading cardiologists in the field of cholesterol research presented a synopsis of the document in the Annals of Internal Medicine in 2018. Some of the highlights include the most obvious recommendations of improving lifestyle habits at an early age in order to decrease the need for drug therapy later in life. Primary prevention, which is treatment for patients with elevated cholesterol levels who have never had cardiovascular disease has always been a difficult subject as the benefits of treatment have been harder to prove conclusively.

Categorizing patients in the age group of 40-75 years into 4 risk groups can help navigate the physician and patient through the different recommendations that may be given to patients by different physicians based on the many studies done through the years. A score of less than 5% indicates low risk and lowering cholesterol should be treated with improving lifestyle habits which we all know is to lower weight, lower the intake of cholesterol in the diet and be involved in regular aerobic exercise. A risk score of greater than 5% calls for a more detailed look at the cholesterol and the patient's total profile. If the LDL level is greater than 190 mg/dl, high intensity statin therapy is recommended even if the patient is perfectly healthy and has no significant risk factors. A more moderate intensity statin therapy recommendation is made to patients with lower LDL levels but who are diabetic. In non-diabetic patients with cholesterol levels between 70-190, the patient's risk running between 5% to over 20% helps determine whether to start treatment. When the risk status is uncertain, measurement of coronary artery calcium (CAC) should be considered for patients with LDL levels between 70-189 who do not have diabetes. A calcium score of 0 would indicate no therapy unless there is diabetes present, there is a family history of premature heart disease or cigarette smoking is present. A calcium score of 1-99 would favor statin therapy especially after the age of 55 even without diabetes. A calcium score of over 100 would significantly favor initiation of statin therapy.

This topic becomes complicated as there are many risk factors that have been looked at, such as chronic kidney disease, the metabolic syndrome, inflammatory disease, (i.e. rheumatoid arthritis), elevated C-reactive protein of over 2.0 mg/L and persistently elevated triglyceride levels of over 175 which would favor therapy although with a lower intensity level of medication. There are also more specific measurements of lipids, such as Lipoprotein (a) levels >50 mg/dl, and Apolipoprotein B >130 mg/dl that would also steer the patient into the treatment group, even in the absence of diabetes or other risk factors.

In conclusion, the decision to start treatment for elevated cholesterol has changed through the years. With the track record of statin the

rapy proving itself to be safe and well tolerated over the past 30 years and with numerous studies showing the cardiac benefits in patients with already proven disease, the expansion of treatment into the general population who are healthy but who are at higher risk of developing heart disease is now becoming an accepted fact and will undoubtedly lead to better cardiac health nationwide in the coming years.

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