2018 Cholesterol Guidelines Updated

Stopping Heart Disease Before It Stops You

I was delighted to see that the new cholesterol management guidelines place a greater emphasis on listening to and understanding patients concerns and preferences for management. (1) While the guidelines still primarily focused on LDL (“bad”) cholesterol reduction there is less “mandate” to initiate therapy earlier in low and intermediate risk patients. Much of the clinical benefit of cholesterol lowering therapy has been in those individuals with established coronary artery disease and a previous heart attack. Doctors should now feel empowered to help their patients explore healthier lifestyle choices. Modifiable lifestyle factors include weight management, heart healthy eating, physical activity, adequate sleep, stress management, and avoidance of environmental toxins such as cigarette smoke, air pollution and toxic metals.  Coronary events such as heart attacks and revascularization procedures including coronary stents and coronary artery bypass surgery can effectively be prevented by implementing such modifiable risk factor alterations.

Below is a figure summarizing these new guidelines. Primary prevention refers to the prevention of cardiovascular risk factors and the subsequent development of atherosclerotic cardiovascular disease (ASCVD). Secondary prevention refers to the management of established ASCVD. Much like it is easier to shut the stable door before the horse escape, primary prevention requires less intensity than secondary prevention. The main limitation of the current medical treatments for hyperlipidemia, such as statin drugs, is not their effectiveness in lowering cholesterol but rather the lack of adherence to the medications. Nearly 60% of individuals prescribed statin drugs for secondary prevention either stop taking the drug or reduce the amount. (2) Thus, we need better options.

Many patients are now looking to alternatives to stain therapy to manage their cardiovascular risk and disease.  Fortunately, 90% of initial heart attacks can be avoided by switching to healthier behaviors. (3) Thanks to Dean Ornish, MD and Caldwell Esselstyn, MD, we know that programs focusing on lifestyle modification can prevent progression of ASCVD and reverse it as well. (4, 5)

To learn more about my integrative strategies for the prevention of atherosclerotic cardiovascular disease visit my web page at www.DaveJohnsonMD.com.

Figure 1. 2018 Guidelines for Cholesterol Management


ASCVD Risk Enhancers:
  • Family history of premature ASCVD
  • Persistently elevated LDL-C ≥ 160 mg/dL or ≥ 4.1 mmol/L
  • Chronic kidney disease
  • Metabolic syndrome
  • Conditions specific to women (e.g., preeclampsia, premature menopause)
  • Inflammatory disease (especially rheumatoid arthritis, psoriasis, HIV)
  • Ethnicity (e.g., South Asian ancestry)
  • Persistently elevated triglycerides ≥ 175 mg/dL, or ≥ 2.0 mmol/L
  • Persistently elevated hs-CRP ≥ 2.o mg/L
  • Elevated lipoprotein (a) [Lp(a)] > 50 mg/dL or > 125 nmol/L
  • apoB ≥ 130 mg/dL
  • Ankle-brachial index (ABI) < 0.9

In intermediate risk patients with an ASCVD risk estimate of 7.5% to 20% consider coronary artery calcification (CAC) imaging

  • CAC = zero (lowers estimated risk; consider no statin, unless diabetes, family history of premature coronary artery disease, or current smoking )
  • CAC = 1-99, favors statin therapy especially after 55
  • CAC = 100+ and/or ≥ 75th percentile, initiate stain therapy
  1. 2018 Colesterol Guidelines, https://www.ahajournals.org/guidelines/cholesterol.
  2. Colantonio LD, et al. Adherence to High_intensity Statins Following Myocardial Infarction Hospitalization Among Medicare Beneficiaries. JAMA Cardiol. 2017;2(8):890-895.
  3. Yusuf S, Hawken S, Ounpuu S, on behalf of the INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004;364:937-952.
  4. Ornish D, Scherwitz LW, Billings JH, et al. Intensive Lifestyle Changes for Reversal of Coronary Heart Disease. JAMA. 1998;280(23):2001–2007. doi:10.1001/jama.280.23.2001
  5. Esselstyn C. A Way to Reverse CAD? The Journal of Family Practice. 2014; 63(7): 356-364.