In 2018, the AHA and ACC, along with other medical societies, published a guideline on the management of blood cholesterol that was an update the previous 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults.
The focus on the current guideline is to outline the best prevention treatments for patients with ASCVD, with consistent attention given to the benefits of clinician–patient risk discussion for making shared decisions.
As a primary prevention, the guideline outlines the efficacy of lifestyle interventions, along with statin treatment, as well as a personalised, accurate method of ASCVD risk assessment. For secondary prevention, the guideline introduces the concept of a ‘very high-risk ASCVD group’, which refers to those patients at greatest risk of recurrent ASCVD events that would benefit the greatest risk reduction from LDL-C lowering. In these patients, the guidelines give recommendations on the addition of non-statin therapies, such as ezetimibe and/or PCKS9 inhibitors, to maximally tolerated statin therapy.
The guidelines also take into account the latest evidence of a causal role of elevated triglycerides in atherosclerosis, with ASCVD event rates remaining high in patients with elevated triglycerides despite statin therapy. As a result, the 2018 AHA/ACC guideline recommends the use of elevated triglycerides as a ‘risk-enhancing factor’ in primary ASCVD prevention, along with treatment strategies targeted to different risk profiles (diet and lifestyle as the first step, while considering statin therapy in those with moderate hypertriglyceridemia and elevated 10-year ASCVD risk).