Updates to the 2018 Cholesterol Guidelines

In this series, Michael Miller, MD, professor of cardiovascular medicine at the University of Maryland School of Medicine, discusses the recent updates to the 2018 cholesterol treatment guidelines. The guideline updates were presented during AHA 2018.

Transcript:

First Report Managed Care:  The new cholesterol management guidelines were just presented at AHA Scientific Session. Can you highlight for us the major updates that were included in those new guidelines?

Dr Miller:  Yes. I think the major updates...The guidelines really add to the most recent one in 2013, but some of the nuances is, now they've spread this kind of risk in primary prevention, so a bit more focus on primary prevention.

What they do now is determine, based on a risk calculator, your risk of having a cardiovascular event over the course of the next 10 years. If your risk is somewhere between 7.5 to 20 percent, then there are other indicators, what we refer to as high-risk indicators, that may put you in the category for whom statin therapy is now recommended.

Those high-risk indicators do include a triglyceride, by the way. If your triglyceride is above the level of 175, that is considered a high-risk indicator. If you're hypertensive, if you have some problem with kidney function, that's a high-risk indicator. If you're not sure, you could do a coronary calcium score, so that's also new.

The coronary calcium score is pretty simple to do, pretty inexpensive. It's usually somewhere at about $100 to $150, and you determine what coronary calcium score is, gets the amount of calcium in your coronaries.

Based on how much calcium you have, for example if you're level is above 100 or if your level is higher than the 73rd percentile of your sex and age group, then you would be a candidate for statin therapy.

First Report Managed Care:  Can you explain how it's determined whether a patient should be prescribed statin versus non-statin to lower their cholesterol levels?

Dr Miller:  Statins are always first-line therapies. The question is, if you have a patient who has coronary disease, for example, and still is viewed as high-risk -- what is high-risk? High-risk might be somebody like a patient has genetic predisposition. They have a condition known as sentimental hypercholesterolemia.

Primary prevention, if their LDL remains above 100 even despite intensive statin therapy, then you can consider adding a non-statin agent. That non-statin agent might include ezetimibe, for example, or a PCSK9 inhibitor.

If they have established, on the other hand, that they do have known heart disease and remain at high risk, and if their LDL is above 70, then you should consider adding a non-statin therapy on top of their statin, again, ezetimibe or PCSK9 inhibitor.

We're using lower cut points, although in general, you want that statin or the medications to reduce their LDL cholesterol, the bad cholesterol, upwards of about 30 to 50 percent or higher, depending upon their level of risk.

First Report Managed Care:  How do these recommendations differ for patients with diabetes mellitus?

Dr Miller:  Again, you have to determine if they have established cardiovascular disease. If they're diabetic by themselves but they never had a heart attack, or stroke, or peripheral event, then they would be viewed as high-risk primary prevention, and then you would use that risk score to determine their 10-year risk.

If they're diabetic but have had an event, then you would view them as having established disease, but they're at very high risk. You'd want to get their LDL down below 70.