Scott M. Grundy, MD, PhD; Neil J. Stone, MD; for the Guideline Writing Committee for the 2018 Cholesterol Guidelines †
Acknowledgment: The authors thank the entire guideline writing committee (Appendix).
Financial Support: By the AHA/ACC.
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-0365.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Catharine B. Stack, PhD, MS, Deputy Editor, Statistics, reports that she has stock holdings in Pfizer, Johnson & Johnson, and Colgate-Palmolive. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose.
Corresponding Author: Neil J. Stone, MD, 676 North St. Clair Street, Suite 600 (Cardiology), Chicago, IL 60611; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Grundy: 5323 Harry Hines Boulevard, Suite Y3.206, Dallas, TX 75390.
Dr. Stone: 676 North St. Clair Street, Suite 600 (Cardiology), Chicago, IL 60611.
Author Contributions: Conception and design: S.M. Grundy, N.J. Stone.
Analysis and interpretation of the data: N.J. Stone.
Drafting of the article: N.J. Stone.
Critical revision of the article for important intellectual content: S.M. Grundy, N.J. Stone.
Final approval of the article: S.M. Grundy, N.J. Stone.
Statistical expertise: S.M. Grundy.
Collection and assembly of data: N.J. Stone.
In November 2018, the American Heart Association and American College of Cardiology (AHA/ACC) released a new clinical practice guideline on cholesterol management. It was accompanied by a risk assessment report on primary prevention of atherosclerotic cardiovascular disease (ASCVD).
A panel of experts free of recent and relevant industry-related conflicts was chosen to carry out systematic reviews and meta-analyses of randomized controlled trials (RCTs) that examined cardiovascular outcomes. High-quality observational studies were used for estimation of ASCVD risk. An independent panel systematically reviewed RCT evidence about the benefits and risks of adding nonstatin medications to statin therapy compared with receiving statin therapy alone in persons who have or are at high risk for ASCVD.
The guideline endorses a heart-healthy lifestyle beginning in childhood to reduce lifetime risk for ASCVD. It contains several new features compared with the 2013 guideline. For secondary prevention, patients at very high risk may be candidates for adding nonstatin medications (ezetimibe or proprotein convertase subtilisin/kexin type 9 [PCSK9] inhibitors) to statin therapy. In primary prevention, a clinician–patient risk discussion is still strongly recommended before a decision is made about statin treatment. The AHA/ACC risk calculator first triages patients into 4 risk categories. Those at intermediate risk deserve a focused clinician–patient discussion before initiation of statin therapy. Among intermediate-risk patients, identification of risk-enhancing factors and coronary artery calcium testing can assist in the decision to use a statin. Compared with the 2013 guideline, the new guideline gives more attention to percentage reduction in low-density lipoprotein cholesterol as a treatment goal and to long-term monitoring of therapeutic efficacy. To simplify monitoring, nonfasting lipid measurements are allowed.
Flow diagram for primary prevention of ASCVD.
Color corresponds to class of recommendation: green = Class I (strong); yellow = Class IIa (moderate); orange = Class IIb (weak). apoB = apolipoprotein B; ASCVD = atherosclerotic cardiovascular disease; CAC = coronary artery calcium; CHD = coronary heart disease; hs-CRP = high-sensitivity C-reactive protein; LDL-C = low-density lipoprotein cholesterol; Lp(a) = lipoprotein(a). (Reproduced from Grundy and colleagues  with permission of the American Heart Association/American College of Cardiology.).
Table. Brief Summary of the 2018 AHA/ACC/Multisociety Cholesterol Guideline
Grundy SM, Stone NJ, for the Guideline Writing Committee for the 2018 Cholesterol Guidelines. 2018 Cholesterol Clinical Practice Guidelines: Synopsis of the 2018 American Heart Association/American College of Cardiology/Multisociety Cholesterol Guideline*. Ann Intern Med. 2019;170:779–783. [Epub ahead of print 28 May 2019]. doi: https://doi.org/10.7326/M19-0365
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Published: Ann Intern Med. 2019;170(11):779-783.
Published at www.annals.org on 28 May 2019
Cardiology, Coronary Risk Factors, Dyslipidemia, Endocrine and Metabolism, Guidelines.
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