Newly released 2018 cholesterol guidelines from the American Heart Association (AHA) and the American College of Cardiology (ACC) emphasize more personalized risk assessments and new drug options for people at the highest risk for atherosclerotic cardiovascular disease (ASCVD).

Chronic kidney disease (CKD; estimated glomerular filtration rate 15–59 mL/min/1.73 m2 with or without albuminuria) is considered one of several risk-enhancing factors. Moderate-intensity statin therapy can be beneficial for adults aged 40 to 75 years with CKD, low density lipoprotein C (LDL-C) of 70 to 189 mg/dL, and a 10-year ASCVD risk of 7.5% or higher. Statin initiation is not recommended for dialysis patients, but those already taking a statin may reasonably continue treatment.

Other risk-enhancing factors include family history of premature ASCVD, LDL-C levels of 160 mg/dL or higher, metabolic syndrome, preeclampsia or premature menopause, chronic inflammatory disorders, high-risk ethnic groups (e.g., South Asian), and triglyceride levels of 175 mg/dL or higher.

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The new guidelines also recommend that moderate-intensity statin therapy should be considered for patients aged 40 to 75 years with diabetes mellitus and LDL-C levels 70 mg/dL or higher. In addition, patients who already have had a myocardial infarction or stroke should receive maximum-intensity statin treatment. Ezetimibe can be added at a LDL-C threshold of 70 mg/dL. After maximally tolerated statin and ezetimibe therapy, it is reasonable to add a PCSK9 inhibitor.

“High cholesterol treatment is not one size fits all, and this guideline strongly establishes the importance of personalized care,” ACC President Michael Valentine, MD, stated in an AHA news release. “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 roadmap for clinicians, we are giving them the tools to help their patients understand and manage their risk and live longer, healthier lives.”

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Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: Executive Summary.  Circ. 2018;0:CIR.0000000000000624

Updated cholesterol guidelines offer more personalized risk assessment, additional treatment options for people at the highest risk: A lifetime approach to lowering cholesterol is still key to reducing cardiovascular risk. American Heart Association; November 10, 2018 (news release)